An evaluation of Chronic Obstructive Pulmonary Disease (COPD) management within the healthcare System of Pakistan: Insights from a Cross-Sectional analysis of GOLD Guidelines implementation

An evaluation of Chronic Obstructive Pulmonary Disease (COPD) management within the healthcare System of Pakistan: Insights from a Cross-Sectional analysis of GOLD Guidelines implementation | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article An evaluation of Chronic Obstructive Pulmonary Disease (COPD) management within the healthcare System of Pakistan: Insights from a Cross-Sectional analysis of GOLD Guidelines implementation Hafsa Kanwal, Amjad Khan, Umm-e- Kalsoom, Saima Mushtaq, Yusra Habib Khan, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4227068/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Recognizing the significance of standardized treatment guidelines in managing COPD, this study aimed to explore prescription patterns in the treatment of chronic obstructive pulmonary disease (COPD). The primary objectives were to assess the extent to which pulmonologists adhere to these guidelines and to pinpoint any factors that may influence physician adherence. Methodology: The research was conducted from April to September 2022 in various healthcare facilities within the twin cities of Pakistan. COPD outpatients were categorized into different risk groups (ABCD) in accordance with the 2021 GOLD strategy. In the context of COPD management, physicians' clinical practices were evaluated by examining both the patients' disease status and the treatment regimens prescribed to determine the degree of adherence to established guidelines. Results: The study included 182 patients, mostly (73.6%) were male with the age mean ± SD 61.16 ± 11.004 years. All patients were Asian Pakistani (100%); 102 (56.0%) patients lived in urban areas, and 80 (44.0%) in rural areas. The most prescribed treatment was the combination long-acting beta agonist (LABA) (27.5%), followed by combination therapy LAMA + LABA (in different inhalers) ((21.4%), LAMA (17.0%), and LABA + ICS (13.7%).The most inappropriate therapies were in Group A (56.09%) followed by a7.5% in Group C. Patients with cardiovascular comorbidities had a .479 (95% CI, .264-.868) times higher risk of receiving an inappropriate therapy (p = 0.015). Conclusions: Pulmonologist compliance with the GOLD guidelines falls short of the desired level and necessitates enhancement. Among the influential factors contributing to the inadequacy of COPD treatments, cardiovascular comorbidities and the inclusion of low-risk Groups A and B are notable, as they carry an elevated risk of overtreatment. Furthermore, it is noteworthy that LABA, while being the most frequently prescribed therapy, is not aligned with the guideline's recommendations to a substantial extent. Adherence to COPD guidelines adherence to GOLD guidelines pulmonologist chronic obstructive pulmonary disease guidelines COPD management in developing country COPD care in Pakistan Figures Figure 1 Introduction COPD has emerged as a significant global public health concern. Despite recent advancements in healthcare systems worldwide, COPD continues to be a prominent cause of both morbidity and mortality (Vogelmeier et al., 2017 ). COPD is a condition that necessitates frequent visits by patients to healthcare facilities and physicians for their routine follow-up appointments. In 2001, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) was established to enhance the diagnosis, management, and prevention of COPD while also devising strategies to enhance treatment outcomes for individuals with COPD. Annually, a new report is compiled through a comprehensive review of published research, with the overarching aim of improving the practices of healthcare providers in COPD management. These GOLD reports are considered indispensable, evidence-based reference materials, serving as the current guidelines for the care of individuals with COPD (Patel, Patel, Singh, Singh, & Khawaja, 2019 ), globally, from 2006 onward, there has been a consistent downward trend in COPD mortality rates, and it is projected that these rates will decrease by 21% by the year 2040 (Gayle, 2022 ). The GOLD guidelines were first introduced in 2011 with the primary objective of offering healthcare providers the most pertinent recommendations for diagnosing and managing COPD patients. Subsequently, significant revisions were made to this handbook in 2006, 2011, 2017, and 2021, with additional minor updates occurring on an almost annual basis. Over time, these guidelines have evolved into an indispensable tool widely utilized in global clinical practices (Albitar & Iyer, 2020 ; Gupta, Malhotra, & Ish, 2021 ). The 2017 version was particular significance as it improved upon the previous ABCD assessment by incorporating patient symptoms and exacerbation history, while no longer relying on spirometry grading. In contrast, the 2021 guidelines introduced certain adjustments in the recommendations for pharmacological treatment and introduced a new chapter addressing COVID-19-related considerations (Ardelean et al., 2012 ;Cojocaru, Marian, & Cojocaru, 2012 ; Han et al., 2021 ). Despite the recognized importance of COPD guidelines for managing the disease across diverse regions, healthcare practitioners responsible for treating various patient demographics have demonstrated suboptimal levels of adherence to these guideline recommendations (Aissa et al., 2020 ; Corrado & Rossi, 2012 ; Ding, Small, & Holmgren, 2017 ; Hsieh et al., 2018 ; Kim et al., 2019 ; Palmiotti et al., 2018 ; Rajnoveanu et al., 2020 ; Sen et al., 2015 ; Sharif, Cuevas, Wang, Arora, & Sharma, 2013 ; Turan et al., 2016 ), specifically over-treating the patients by prescribing the inhaled corticosteroids (ICS)(Palmiotti et al., 2018 ). The World Health Organization (WHO) notes that the determinants of physicians' adherence to guidelines, particularly those specializing in pulmonology, are highly intricate and encompass not only the healthcare provider but also factors related to the patient, the disease itself, and various social factors (Aissa et al., 2020 ; Ulmeanu, Mihaltan, Arghir, Mladinescu, & Teodorescu, 2016 ). Regardless of the obstacles encountered, inadequate adherence has a detrimental impact on patients' clinical outcomes, heightening the risk of unforeseen acute exacerbations of COPD, and positive treatment outcomes (Hogea et al., 2020 ; Sandu, Mihaescu, Filipeanu, Cernomaz, & Crisan-Dabija, 2019 )(Aissa et al., 2020 ). Improved adherence, on the other hand, has clinical and functional benefits as well as economic benefits that reduce direct and indirect healthcare expenditures (Asche et al., 2012 ; Chan et al., 2017 ; Chiang, Liu, Chuang, & Jheng, 2013 ; Miravitlles et al., 2013 ; Sen et al., 2015 ). The majority of researches on physician adherence to the GOLD guidelines have been undertaken at multiple levels—regional, and international. (Asche et al., 2012 ; Cojocaru et al., 2012 ; Duarte-de-Araújo, Teixeira, Hespanhol, & Correia-de-Sousa, 2020 ; Hsieh et al., 2018 ; Kim et al., 2019 ; Palmiotti et al., 2018 ; Sandu et al., 2019 ; Sen et al., 2015 ; Vogelmeier et al., 2017 ),still there is no study to assess the adherence to GOLD guidelines has been conducted in Pakistan. Due to the highest variability in study results (Gupta et al., 2021 ; Sehl, O’Doherty, O’Connor, O’Sullivan, & O’Regan, 2018 ) it is impossible to extrapolate the study results to Pakistan. These studies have been conducted not only among pulmonologists, but also among specialists involved in COPD treatment (Surani et al., 2019 ), for the assessment of different GOLD guidelines (Palmiotti et al., 2018 ). A study emphasized the relevance of improving recommendations' implementation in healthcare settings by streamlining their dissemination (Sen et al., 2015 ). Enhanced collaboration between healthcare professionals and policy-making entities responsible for guideline implementation is essential. This collaboration aims to identify barriers to adherence and tailor recommendations to align with the practical needs of everyday healthcare delivery (Ardelean et al., 2012 ). Considering these observations, it was valuable to assess the extent of pulmonologists' familiarity with and utilization of COPD management guidelines in Pakistan. This assessment is particularly pertinent given that a 2019 study estimated the overall prevalence of this condition at 2.1% within the adult population in the country (Khan et al., 2019 ). The present study has exclusively concentrated on the practices of physicians pertaining to COPD management. Methods Aim : The study's primary objectives encompass the following: (1) assess prevailing pharmacological prescription practices for COPD treatment aligned with the 2021 GOLD guidelines, (2) ascertain the extent of adherence among pulmonologists, and (3) identify potential factors that may exert influence on adherence to therapeutic guidelines. Study Design and Study Setting : This cross sectional observational study was conducted from April 1st to September 30th, 2022, across various healthcare facilities in the twin cities of Pakistan. The study involved the collection of outpatient prescriptions and comprehensive medical records. Study Participants : Inclusion criteria encompassed patients meeting the following criteria: a documented diagnosis of COPD confirmed by a pulmonologist through clinical history, physical examination, and spirometric assessment; a stable form of the condition; age equal to or greater than 40 years; and classification into the ABCD risk groups based on symptoms and exacerbation history according to the 2021 GOLD guidelines. Exclusion criteria comprised of inpatients, individuals younger than 40 years of age, those lacking a confirmed COPD diagnosis, incomplete medical records (specifically, the absence of GOLD stage/group information), and patients presenting with acute COPD exacerbations or concurrent asthma diagnoses. Data Collection : Each patient was assigned a unique reference number corresponding to their inclusion sequence within the study. The following data points were gathered: age, gender, residential location (categorized as urban or rural), smoking history, and spirometry-based classification of airflow limitation severity, spanning from GOLD Grades 1 to 4. Symptom assessment was conducted using the COPD Assessment Test (CAT), while the level of breathlessness was measured utilizing the Modified British Medical Research Council (mMRC) Questionnaire. Subsequently, based on their CAT and mMRC scores, patients were categorized into the ABCD groups. Groups A and B, characterized by lower exacerbation rates in comparison to C and D, are deemed as the low-risk categories, whereas C and D represent the high-risk groups with a higher likelihood of exacerbation (Rajnoveanu et al., 2020 ). Comorbidities (cardiovascular diseases), the presence of a chronic respiratory failure diagnosis in the patient medical records, first consultation or regular follow-up visit, inhaled pharmacological medications prescribed for COPD as a monotherapy or in different combinations of short-acting beta agonists (SABA), long-acting beta agonists (LABA), short-acting antimuscarinic agents (SAMA), long-acting antimuscarinic agents (LAMA), and inhaled corticosteroids (ICS). Comorbid cardiovascular disease consists of arterial hypertension, ischemic heart disease, heart failure, arrhythmias, and valvopathies, as they were mentioned in the patients’ medical records. Assessment Criteria for Adherence to the GOLD Guidelines Adherence was characterized as suitable when the prescribed pharmacological therapy aligned with the guidelines, either as the primary or alternative medication option, while it was considered inappropriate if it did not adhere to these recommendations. Furthermore, inappropriate therapy was categorized as either overtreatment or under-treatment. The evaluation of suitable therapy was carried out in accordance with the dedicated 2021 GOLD algorithms specific to the treatment of each risk group (Table 1 ). Table 1 Treatment algorithm according to the GOLD guidelines 2021 Appropriateness ( Concordance with the GOLD guidelines Inappropriateness (Discordance with the GOLD guidelines) Group First Choice Alternative Choice Under-treatment Over-treatment A A bronchodilator Change the bronchodilator No bronchodilator prescribed LABA + LAMA, ICS or any combination treatment B LAMA or LABA LAMA + LABA Only short-acting bronchodilator LAMA + LABA + ICS, ICS + LABA, ICS + LAMA C LAMA LAMA + LABA or ICS + LABA Only ICS or LABA or SABA ICS + LAMA, ICS + LABA + LAMA D LAMA + LABA or LAMA or ICS + LABA If still exacerbation resent ICS + LABA + LAMA Only ICS or SABA or LABA, ICS + LAMA Statistical Analysis Data collection was initially conducted in Microsoft Excel software, and subsequently was imported into SPSS software (IBM SPSS Statistics 25.0) for comprehensive statistical analysis. Quantitative variables were represented as either the median, mean ± standard deviation (SD), or with a 95% confidence interval (CI). Qualitative variables were presented in terms of absolute figures and relative percentages. Statistical analyses involved the utilization of the chi-squared test to compare frequencies, while the t-test for independent samples was employed to compare means between two sets of normally distributed variables. The threshold for statistical significance was established at p < 0.05. Results The study encompassed a total of 182 patients who sought consultations from nine different pulmonologists. A pool of 294 patients was excluded from the analysis due to the absence of documented COPD stage/group information, incomplete records regarding smoking history, and insufficient disease history details. Nevertheless, even within the included patient cohort, some data were missing. Although all the data were retrospective, certain components such as the CAT and mMRC questionnaires were administered during the study to categorize patients into the ABCD groups. Table 2 presents the baseline characteristics of the COPD patients. The mean age of the study participants was 61.16 years, with a standard deviation of 11.004 years. Male patients constituted the majority at 73.6%, while females accounted for 26.4%. All patients were of Asian Pakistani origin (100%), with 102 (56.0%) residing in urban areas and 80 (44.0%) in rural locales. Among the 182 patients, smoking history data were available for 97 individuals, representing 53.29% of the sample, and of these, only 76 patients had recorded smoking pack-years, with an average of 52 ± 12.26 pack years. Table 2 Demographic characteristics of Chronic Obstructive Pulmonary Disease (COPD) patients Demographics Age (Mean (SD)) 61.16(11.00) Gender, n (%) Male 134(73.6) Female 48(26.4) Residency, n (%) Urban 102(56.0) Rural 80(44) Smoking history, n (%) Currently doing 61(33.51) Quit smoking 97(53.29) No smoking 24 (13.18) Spirometric GOLD grade, n (%) Gold 1 24(22.6) Gold 2 45(42.45) Gold 3 17(16.3) Gold 4 20(18.8) GOLD group, n (%) GRADE A 41(22.5) GRADE B 75(41.2) GRADE C 40(22.0) GRADE D 26(14.3) Cardiovascular co-morbidity, n (%) Yes 85(46.7) No 97(53.3) According to the GOLD spirometry grades, 41.2% of the patients fell under GOLD 2. When classified using symptoms and a history of acute exacerbations to determine the refined 2021 GOLD ABCD groups, the majority of patients were categorized into Group B (41.2%). Among current smokers, Group A and Group B were the most prevalent, at 30.0% and 22.24%, respectively. Cardiovascular co-morbidities were present in 46.7% of COPD patients, but data regarding chronic respiratory failure were not available. The distribution of therapeutic regimens varied among the GOLD ABCD groups, as detailed in Table 3 . In general, the most frequently prescribed maintenance treatment was the combination of LAMA, accounting for 27.5%, followed by LAMA + LABA combination therapy (administered through separate inhalers) at 21.4%, standalone LAMA therapy at 17.0%, and LABA + ICS combination therapy at 13.7%. Table 3 Medications used by the COPD patients for the disease management according to ABCD classification GOLD classification Total Grade A Grade B Grade C Grade D Treatment Regimen In COPD patients SABA 2(4.9) 6(8) 0(0) 0(0) 10(5.5) LABA 16(39) 26(34.7) 6(15) 2(7.7) 50(27.5) LAMA 10(24.4) 13(17.3) 5(12.5) 3(11.5) 31(17) LAMA + LABA 8(19.5) 22(29.3) 7(17.5) 2(7.7) 39(21.4) ICS 0(0) 2(2.7) 0(0) 0(0) 2(1.1) LAMA + ICS 0(0) 0(0) 7(17.5) 4(15.38) 11(6.04) LABA + ICS 3(7.3) 6(8) 7(17.5) 5(19.23) 25(13.7) LAMA + LABA + ICS 0(0) 0(0) 8(20) 10(38.5) 18(9.9) Out of the initial 182 patients meeting the inclusion criteria, 100 individuals (54.90%) received the appropriate therapy, demonstrating a 54.90% adherence rate to the GOLD guidelines. The suitability and inappropriateness of pharmacological treatments exhibited variations among each of the ABCD groups (Fig. 1). Table 4 Frequency distribution of under−treatment and over−treatment in ABCD groups in patients receiving inappropriate treatment Treatment Inappropriate treatment Under treatment Over treatment GOLD Classification GRADE A 2 21 23 GRADE B 12 16 28 GRADE C 6 14 19 GRADE D 12 0 12 Total 32 51 83 As shown in Table 5 , the most inappropriate therapy was observed among patients in Group A, with 43.9% of cases falling into this category. This group exhibited overtreatment in 56.09% of instances, with 24.4% receiving LAMA, 19.5% receiving LAMA + LABA, and 7.3% receiving LABA + ICS, while under-treatment was identified in 4.9% of patients who did not receive a disease-specific treatment. Table 5 Treatment appropriateness and inappropriateness among the low risk groups A and B and high risk groups C and D Appropriate (n = 101) In Appropriate (n = 81) Independent Sample Test-Statistics P-value Age(Mean, SD) 60.01(11.207) 62.59(10.642) t=-1.580 .116 Gender Male 69(68.3) 65(80.2) \({\chi }^{2}\) =5.295 .023 Female 32(31.7) 16(19.8) Residence Urban 62(61.4) 40(49.4) \({\chi }^{2}\) =2.629 .105 Rural 39(38.6) 41(50.6) Cardiovascular comorbidities Yes 39(38.6) 46(56.8) \({\chi }^{2}\) =5.966 .015 No 62(61.4) 35(43.2) Groups A and B (n) vs. Groups C and D (n) 66 vs 35 50 vs 31 \({\chi }^{2}\) =.255 .614 Groups A and B (n) vs. Groups C and D (n) Odd ratio = 1.169 (95% CI, .637-2.146) Cardiovascular comorbidities to with and without appropriateness: Odd ratio = .479 (95% CI, .264-.868) Among Group C patients, 47.5% received inappropriate (overtreatment) prescriptions, predominantly with LABA + ICS (17.5%) and LABA + LAMA + ICS (20.0%), whereas under-treatment was observed with LABA (15.0%). In Group D patients, 46.15% were treated inappropriately, with under-treatment seen in 7.7% for LABA, 11.5% for LAMA, 7.7% for LAMA + LABA, and 19.23% for LABA + ICS. Notably, ICS overprescription occurred in 23% of cases, either as a sole therapy or in combination. Chi-squared test was conducted to examine the inappropriateness of prescriptions between the high-risk exacerbation groups (C and D), which were recommended by the GOLD 2021 guidelines, in comparison to the low-risk exacerbation groups (A and B). The results did not show statistical significance (p = 0.614), indicating a consistent trend of inappropriateness across all the ABCD groups. Patients in Groups C and D had an odds ratio (OR) of 1.169 with a 95% confidence interval (CI-0.637-2.146), suggesting a similar pattern of inappropriateness among all ABCD groups. The frequency of treatment concordance recorded statistically significant differences between patients with and without cardiovascular comorbidities ( p = 0.015), with an OR of .479 (95% CI, .264-.868) Discussion Previous research revealed that device preference, insufficient symptom evaluation, pulmonologist carelessness, and optimism for steroid effectiveness were associated with low adherence to the GOLD standards (Chan et al., 2017 ; Turan et al., 2016 ; White, Thornton, Pinnock, Georgopoulou, & Booth, 2013 ) that was also same in our observation. Our study noted that these observations remained consistent, with spirometry still being the least frequently utilized device. Initially, out of a pool of 478 patients, only 182 underwent spirometry testing, signifying a spirometry utilization rate of 38.49%, and a majority of these tests were conducted in private clinics. Additionally, for the purpose of ABCD classification, we introduced the practice of administering CAT and mMRC assessments ourselves, which had not been previously implemented within our study sample or in healthcare practices elsewhere. The core findings of our research were the showed comparatively less adherence of healthcare practitioners to the 2021 GOLD guidelines (54.90%), that was quite similar to the following study (White et al., 2013 ) having (58.1%) adherence to GOLD guidelines. A Turkish study showed that only 40.4% of COPD patients received GOLD guideline-concordant treatments(Turan et al., 2016 ).The association between inappropriate treatment prescriptions and comorbid cardiovascular disease (.479 higher risk). LABA containing regimen either alone or in combination was the most prescribed drug according to our study with (72.5%). The primary aim of this study was to evaluate the compliance of pulmonologists and general practitioners with the recently updated GOLD guidelines. Adherence to healthcare guidelines is defined by the US National Library of Medicine as "conformity in fulfilling or following official, established guidelines, recommendations, protocols" when applying them within the clinical setting (medicines). While grasping the concept of adherence to guidelines is straightforward, the actual execution can be challenging (López-Campos, Quintana Gallego, & Carrasco Hernández, 2019 ). Numerous studies conducted across various regions and states worldwide have employed similar metrics to gauge the adherence of healthcare practitioners to the current GOLD guidelines (Chinai, Hunter, & Roy, 2019 ; Duarte-de-Araújo et al., 2020 ; Hsieh et al., 2018 ; Kim et al., 2019 ; Palmiotti et al., 2018 ; Patel et al., 2019 ; Sharif et al., 2013 ; Turan et al., 2016 ) to the metrics we use in our study. In present study the overall adherence to the recent GOLD guidelines was 54.90% that was similar to the study conducted in western Europe and USA where adherence to the guidelines was 58.25%(Ding et al., 2017 ) and higher comparing to the most of the previously published studies i.e. 49.6% in South Korea (Kim et al., 2019 ), 44.9% in Taiwan the capital of Iran (Chiang et al., 2013 ) 29.7% in Tunisia and the Maghreb (probably the lowest adherence level to the GOLD guidelines(Vogelmeier et al., 2017 ). However, some studies reported higher level of adherence than our study results included 61.6% in Turkey (Martins et al., 2021 ), 70% reported by Palmiotti and coworkers and 79.02% by Rajnoveanu and his team(Chinai et al., 2019 ) Although there is no limit of percent adherence to guidelines, it is continuous process that can be improved (Chan et al., 2017 ). The demographic and clinical characteristics of our study population closely resembled those observed in other studies. Specifically, our cohort consisted of 184 COPD patients, which was lower than the sample size of 296 in the study conducted by Aissa et al. and larger than the study conducted by Chinai and colleagues, which had a sample size of 154, respectively (Aissa et al., 2020 ; Chinai et al., 2019 ). As is the case in numerous other studies within this field, males constituted the majority at 73.6% (Aissa et al., 2020 ; Duarte-de-Araújo et al., 2020 ; Hsieh et al., 2018 ; Kim et al., 2019 ; Palmiotti et al., 2018 ), while the mean age was lower than the previously conducted studies (Kim et al., 2019 ; Patel et al., 2019 ). In terms of smoking status, the outcomes of our study closely paralleled those reported in studies conducted in Italy and Romania, respectively (Miravitlles et al., 2013 ; Rajnoveanu et al., 2020 ). However, the proportion of current smokers among COPD patients, at 23.0%, was concerning. This suggests a potential deficiency in tobacco treatment programs, as well as a lack of active smoking cessation campaigns or counseling efforts in Pakistan (Martins et al., 2021 ). According to the present study, the adherence rate was different in all the COPD groups ABCD, higher level of appropriateness was seen 75% in low risk exacerbation risk B group followed by high risk exacerbation groups C and D where level of adherence was 52.5% and 53.84% respectively. Low level of adherence was observed 43.9% in Group A showing consistency with other studies (Martins et al., 2021 ; Palmiotti et al., 2018 ; Turan et al., 2016 ; Vogelmeier et al., 2017 ), emphasized that COPD patients from this GOLD Groups and from various countries are not being treated adequately by the medical professionals (Patel et al., 2019 ). Taken together, each ABCD group displayed a similar propensity to receive inappropriate treatment. However, groups A and B exhibited a 1.169-fold higher likelihood of receiving inappropriate treatment compared to those in groups C and D (p = 0.614). These findings underscore the importance of healthcare practitioners consulting the GOLD guidelines when prescribing for patients in both the low-risk groups A and B, as well as the high-risk groups C and D, in accordance with the guideline recommendations. It's worth noting that the majority of patients treated in healthcare settings belonged to group B, comprising 75 individuals (41.2%), consistent with findings from previous studies (Chiang et al., 2013 ; Palmiotti et al., 2018 ; Vogelmeier et al., 2017 ) and adherence rate was also higher in this group contrary to the previous studies(Chan et al., 2017 ; Ding et al., 2017 ). Regarding the findings of our study, a notable observation pertains to the prevalence of overtreatment, with the highest occurrence observed in group A, where patients typically require fewer medications. Conversely, it's worth highlighting that no cases of overtreatment were identified in GOLD Group D, aligning with similar findings reported in this study (Asche et al., 2012 ). These findings can likely be attributed to the fact that patients falling into this category, characterized by a substantial symptom burden and a heightened risk of exacerbation, typically receive maximal therapy (LAMA + LABA + ICS) in the event of further exacerbations. Consequently, there is minimal possibility of overtreatment in this group (Ray et al., 2019 ; Vogelmeier et al., 2017 ). The presence of cardiovascular comorbidities emerged as another pivotal factor influencing the alignment of therapeutic prescriptions with guideline recommendations. Among COPD patients, the most prevalent concurrent conditions included cardiovascular ailments, lung cancer, obstructive sleep apnea, as well as anxiety and depression (Budin et al., 2019 ; Jimborean et al., 2018 ; Rabe, Hurst, & Suissa, 2018 ; Sekine, Katsura, Koh, Hiroshima, & Fujisawa, 2012 ). These coexisting medical conditions can exert an influence on health status, disease advancement, and prognosis (Budin et al., 2019 ). Roughly half of the participants in our study, approximately 46.7%, exhibited cardiovascular comorbidities. This comorbidity significantly affected the adherence of pulmonologists to the GOLD criteria. A prior study conducted by Sharif et al. had also noted a heightened prevalence of cardiovascular comorbidities in COPD patients (Sharif et al., 2013 ). Nonetheless, the outcomes of our study revealed a statistically significant variation in adherence among patients with cardiovascular comorbidities (p = 0.015). These findings underscore the importance of increasing healthcare practitioners' vigilance not only in identifying comorbidities but also in exercising greater caution when prescribing treatments for COPD in patients with concurrent cardiovascular diseases. It's imperative to recognize that therapies for one condition may impact the other, underscoring the critical need for appropriate treatment strategies addressing both conditions (Rabe et al., 2018 ). Among COPD patients with cardiovascular issues, inappropriate treatments encompassed both under- and over treatment. Under-treatment might be attributed to prior apprehensions regarding an elevated risk of cardiovascular events associated with the initial use of LAMA and LABA medications. This concern persisted despite the generally favorable safety profile of these long-standing medications (Rabe et al., 2018 ). The safety of bronchodilators may pose a concern in cases of over-treatment. Nevertheless, there exists inconclusive evidence regarding the association between bronchodilator usage and cardiovascular events in COPD patients. Certain studies have indicated a heightened risk of cardiovascular events associated with bronchodilator use, whereas others have found no evidence of such a risk. Additionally, some studies have even suggested a reduction in risk among COPD patients using bronchodilators (Calverley et al., 2010 ; Gershon et al., 2013 ; Singh, Loke, & Furberg, 2008 ; Tashkin et al., 2008 ) In the current study, LABA therapy was the most frequently prescribed, accounting for 27.5%, and LABA + LAMA was the second most commonly prescribed therapy, representing 21.4% of cases. This contrasts with findings from other studies where the most commonly prescribed therapeutic regimen was LAMA + LABA (Rajnoveanu et al., 2020 ; Turan et al., 2016 ). According to the results of the current study, ICS was notably less commonly prescribed, either as a standalone therapy or in combination regimens. However, the incidence of overtreatment with ICS in groups A and B was 18%, which closely resembled the findings of a prior study where overtreatment with ICS was observed at a rate of 17.81%. This outcome was surprising since previous studies had identified ICS as the most prevalent type of inappropriateness (Palmiotti et al., 2018 ; Petite, 2018 ; Price et al., 2014 ; Sen et al., 2015 ; Stafyla, Kotsiou, Deskata, & Gourgoulianis, 2018 ). GOLD guidelines recommend the use of ICS in patients with a history of exacerbations (Group C and D), but not in those without such a history (Group A and B). Although there was no significant use of ICS observed in the low-risk groups, a small percentage of patients were prescribed ICS in Group A (7.3%) and Group B (10.2%), either as a single therapy or in combination. This prescribing pattern contradicts the findings typically reported in studies such as the TOLD study, the KOCOSS study, and the Portuguese study conducted by Duarte-de-Araujo (Hsieh et al., 2018 ; Kim et al., 2019 ; Ulmeanu et al., 2016 ; Wei et al., 2015 ). Furthermore, an examination of the local context might shed light on additional factors contributing to the persistent overtreatment of individuals with lower GOLD grades. In the local market, the availability of a sole LABA medication, coupled with the discontinuation of LABA and LABA + LAMA options in drug stores, resulted in an increased tendency to prescribe the ICS + LABA combination. The male gender was linked to a heightened likelihood of receiving inappropriate therapy. Interpretation of these findings is challenging due to the limited data available in the literature concerning such outcomes, highlighting the necessity for additional research in this area. Notably, our study, to the best of our knowledge, represents the first investigation in Pakistan to address the issue of pulmonologist adherence to the GOLD 2017 guidelines, which is a notable strength. Additionally, the inclusion of patients with cardiovascular disease, a group typically excluded from controlled trials, is another noteworthy aspect of our study. Certainly, our research is subject to certain limitations. Firstly, given that this study was conducted within a single region and with a relatively small sample size, it is important to exercise caution when generalizing the findings to other regions of the country. Secondly, as COPD patients are still underdiagnosed or not consistently categorized according to GOLD risk groups, the study's design, which encompassed all patients classified within the ABCD categories, may not fully mirror real-world scenarios. The presence of a substantial number of ineligible patients, lacking COPD stage/group indications in their records, might potentially lead to an overestimation of pulmonologist adherence. Another drawback is the absence of patient follow-up data, which means there is no available evidence regarding the long-term management of stable COPD. Moreover, it's important to note that the current study does not provide insights into adherence to non-pharmacological treatments or the utilization of alternative pharmacological medications. Additionally, the study did not examine various pivotal practical factors, including the accessibility and affordability of pharmaceuticals. Given that the healthcare system lacks a centralized body responsible for covering treatment costs, these factors can significantly influence medication prescription practices, potentially accounting for deviations among pulmonologists from guideline recommendations. In conclusion, based on our findings, we offer several recommendations that could prove beneficial for clinical practice in Pakistan. First and foremost, there is a pressing need for a more appropriate implementation of COPD guidelines, commencing with an accurate and comprehensive diagnosis that subsequently guides appropriate therapy. Furthermore, healthcare professionals across the board should pay special attention to patients falling within low-risk Groups A and B, as well as those who present with concurrent cardiovascular conditions. Conclusions Our research has identified that the adherence of pulmonologists to the GOLD criteria falls short of the desired level and warrants improvement. Notably, the presence of cardiovascular comorbidities and the inclusion of patients in the low-risk categories (A and B) emerge as pivotal factors influencing the appropriateness of COPD treatment. Furthermore, it is noteworthy that even among individuals at low risk of exacerbation, the most prevalent form of over treatment involves regimens containing inhaled corticosteroids (ICS). To bridge the disparity between guideline recommendations and real-world clinical practice, it is imperative to conduct additional multicenter studies encompassing all potential factors that may impact adherence rates. Abbreviations GOLD: Guidelines for Chronic Obstructive Lung Disease ICS: Inhaled corticosteroid CAT: COPD assessment test COPD: Chronic obstructive pulmonary disease PFT: Pulmonary function test SPSS: Statistical Package for the Social Sciences FEV1: Forced expiratory volume in one second FVC : Forced vital capacity LABA: Long-acting β 2 agonist SABA: Short-acting β 2 agonist LAMA: Long-acting muscarinic antagonist SAMA: Short-acting muscarinic antagonists mMRC: Modified Medical Research Council Declarations Ethics approval The study was approved by the bio-ethical committee of Quaid-i-Azam University, Islamabad, Pakistan, under the No. #BEC-FBS-QAU2021-269 and from the study site i.e. Holy Family Hospital, Rawalpindi, Pakistan, under the Ref. No.63/IREF/RMU/2021. Consent to participate A signed consent was obtained from every participant during the study by the principle investigator. Competing interests N/A Funding N/A Acknowledgement We are thankful to the Higher Education Commission (HEC), Pakistan for providing a grant under the National Research Program for Universities- NRPU Ref No. 20-14413/NRPU/R&D/HEC/2021. Availability of data and materials The datasets utilized or examined in the present study can be obtained upon a reasonable request directed to the corresponding author. Author Contribution Hafsa K , and Amjad K conceived and designed the study; Hafsa K and Umm E K collected the data and Mahwish R has analyzed the data; Hafsa K and Umm E K, prepared the original draft; Yusra H K and Yu F critically evaluated and finalized the manuscript; all authors approved the manuscript. References Aissa, S., Knaz, A., Maatoug, J., Khedher, A., Benzarti, W., Abdelghani, A., . . . Gargouri, I. (2020). Adherence of North-African Pulmonologists to the 2017-Global Initiative for Chronic Obstructive Lung Disease (GOLD) Pharmacological Treatment Guidelines (PTGs) of Stable Chronic Obstructive Pulmonary Disease (COPD). BioMed Research International, 2020 . Albitar, H. A. H., & Iyer, V. N. (2020). Adherence to Global Initiative for Chronic Obstructive Lung Disease guidelines in the real world: current understanding, barriers, and solutions. Current Opinion in Pulmonary Medicine, 26 (2), 149-154. Ardelean, D. L., Iulia, L., Popescu, R., Didilescu, C., Dinescu, S., Olteanu, M., & Niţu, M. (2012). Evaluation of COPD patients using CAT-COPD assessment test. Pneumologia (Bucharest, Romania), 61 (4), 221-229. Asche, C. V., Leader, S., Plauschinat, C., Raparla, S., Yan, M., Ye, X., & Young, D. (2012). Adherence to current guidelines for chronic obstructive pulmonary disease (COPD) among patients treated with combination of long-acting bronchodilators or inhaled corticosteroids. International journal of chronic obstructive pulmonary disease , 201-209. Budin, C. E., Maierean, A. D., Ianosi, E. S., Socaci, A., Buzoianu, A. D., Alexescu, T. G., . . . Nemes, R. M. (2019). Nocturnal hypoxemia, a key parameter in overlap syndrome. Rev Chim, 70 (2), 449-454. Calverley, P. M., Anderson, J. A., Celli, B., Ferguson, G. T., Jenkins, C., Jones, P. W., . . . Vestbo, J. (2010). Cardiovascular events in patients with COPD: TORCH study results. Thorax, 65 (8), 719-725. Chan, K. P., Ko, F. W., Chan, H. S., Wong, M. L., Mok, T. Y., Choo, K. L., & Hui, D. S. (2017). Adherence to a COPD treatment guideline among patients in Hong Kong. International journal of chronic obstructive pulmonary disease , 3371-3379. Chiang, C.-H., Liu, S.-L., Chuang, C.-H., & Jheng, Y.-H. (2013). Effects of guideline-oriented pharmacotherapy in patients with newly diagnosed COPD: a prospective study. Wiener klinische Wochenschrift, 125 . Chinai, B., Hunter, K., & Roy, S. (2019). Outpatient management of chronic obstructive pulmonary disease: physician adherence to the 2017 global initiative for chronic obstructive lung disease guidelines and its effect on patient outcomes. Journal of Clinical Medicine Research, 11 (8), 556. Cojocaru, C., Marian, M., & Cojocaru, E. (2012). La perception de la fatigue chez les patients avec broncho-pneumonie chronique obstructive. Revue des Maladies Respiratoires, 29 , A58. Corrado, A., & Rossi, A. (2012). How far is real life from COPD therapy guidelines? An Italian observational study. Respiratory medicine, 106 (7), 989-997. Ding, B., Small, M., & Holmgren, U. (2017). A cross-sectional survey of current treatment and symptom burden of patients with COPD consulting for routine care according to GOLD 2014 classifications. International journal of chronic obstructive pulmonary disease , 1527-1537. Duarte-de-Araújo, A., Teixeira, P., Hespanhol, V., & Correia-de-Sousa, J. (2020). COPD: analysing factors associated with a successful treatment. Pulmonology, 26 (2), 66-72. Gayle, A. (2022). Understanding the burden of COPD mortality: An investigation using UK electronic healthcare record data. Gershon, A., Croxford, R., Calzavara, A., To, T., Stanbrook, M. B., Upshur, R., & Stukel, T. A. (2013). Cardiovascular safety of inhaled long-acting bronchodilators in individuals with chronic obstructive pulmonary disease. JAMA internal medicine, 173 (13), 1175-1185. Gupta, N., Malhotra, N., & Ish, P. (2021). GOLD 2021 guidelines for COPD—what’s new and why. Advances in respiratory medicine, 89 (3), 344-346. Han, V. X., Patel, S., Jones, H. F., Nielsen, T. C., Mohammad, S. S., Hofer, M. J., . . . Nassar, N. (2021). Maternal acute and chronic inflammation in pregnancy is associated with common neurodevelopmental disorders: a systematic review. Translational psychiatry, 11 (1), 71. Hogea, S. P., Tudorache, E., Fildan, A. P., Fira‐Mladinescu, O., Marc, M., & Oancea, C. (2020). Risk factors of chronic obstructive pulmonary disease exacerbations. The clinical respiratory journal, 14 (3), 183-197. Hsieh, M.-J., Huang, S.-Y., Yang, T.-M., Tao, C.-W., Cheng, S.-L., Lee, C.-H., . . . Hsu, W.-H. (2018). The impact of 2011 and 2017 Global Initiative for Chronic Obstructive Pulmonary Disease (GOLD) guidelines on allocation and pharmacological management of patients with COPD in Taiwan: Taiwan Obstructive Lung Disease (TOLD) study. International journal of chronic obstructive pulmonary disease , 2949-2959. Jimborean, G., Szasz, S., Szathmary, M., Csipor, A., Arghir, O. C., Nemes, R. M., . . . Ianosi, E. S. (2018). Association Between Chronic Obstructive Pulmonary Disease and Sleep Apnea—Overlap Syndrome—Experience of Pulmonology Clinic Tg. Mures, Romania. Rev. Chim. Buchar, 69 , 1014-1017. Khan, M. A., Khan, M. A., Walley, J. D., Khan, N., Sheikh, F. I., Ali, S., . . . Manzoor, F. (2019). Feasibility of delivering integrated COPD-asthma care at primary and secondary level public healthcare facilities in Pakistan: a process evaluation. BJGP open, 3 (1). Kim, T.-O., Shin, H.-J., Kim, Y.-I., Rhee, C.-K., Lee, W.-Y., Lim, S.-Y., . . . Park, S.-J. (2019). Adherence to the GOLD guideline in COPD management of South Korea: findings from KOCOSS study 2011–2018. Chonnam Medical Journal, 55 (1), 47-53. López-Campos, J. L., Quintana Gallego, E., & Carrasco Hernández, L. (2019). Status of and strategies for improving adherence to COPD treatment. International journal of chronic obstructive pulmonary disease , 1503-1515. Martins, R. S., Junaid, M. U., Khan, M. S., Aziz, N., Fazal, Z. Z., Umoodi, M., . . . Khan, J. A. (2021). Factors motivating smoking cessation: a cross-sectional study in a lower-middle-income country. BMC public health, 21 (1), 1-11. medicines, U. s. n. l. o. Miravitlles, M., Sicras, A., Crespo, C., Cuesta, M., Brosa, M., Galera, J., . . . Riera, M. I. (2013). Costs of chronic obstructive pulmonary disease in relation to compliance with guidelines: a study in the primary care setting. Therapeutic advances in respiratory disease, 7 (3), 139-150. Palmiotti, G. A., Lacedonia, D., Liotino, V., Schino, P., Satriano, F., Di Napoli, P. L., . . . Carone, M. (2018). Adherence to GOLD guidelines in real-life COPD management in the Puglia region of Italy. International journal of chronic obstructive pulmonary disease , 2455-2462. Patel, A. R., Patel, A. R., Singh, S., Singh, S., & Khawaja, I. (2019). Global initiative for chronic obstructive lung disease: the changes made. Cureus, 11 (6). Petite, S. E. (2018). Characterization of chronic obstructive pulmonary disease prescribing patterns in the United States. Pulmonary Pharmacology & Therapeutics, 49 , 119-122. Price, D., West, D., Brusselle, G., Gruffydd-Jones, K., Jones, R., Miravitlles, M., . . . Stewart, R. (2014). Management of COPD in the UK primary-care setting: an analysis of real-life prescribing patterns. International journal of chronic obstructive pulmonary disease , 889-905. Rabe, K. F., Hurst, J. R., & Suissa, S. (2018). Cardiovascular disease and COPD: dangerous liaisons? European Respiratory Review, 27 (149). Rajnoveanu, R.-M., Rajnoveanu, A.-G., Ardelean, A.-B., Todea, D. A., Pop, C.-M., Antoniu, S. A., . . . Man, M. A. (2020). Pulmonologists adherence to the chronic obstructive pulmonary disease GOLD Guidelines: a goal to improve. Medicina, 56 (9), 422. Ray, R., Hahn, B., Stanford, R. H., White, J., Essoi, B., & Hunter, A. G. (2019). Classification of patients with COPD on LAMA monotherapy using the GOLD criteria: analysis of a claims-linked patient survey study. Pulmonary Therapy, 5 , 191-200. Sandu, V. M., Mihaescu, T., Filipeanu, D., Cernomaz, A., & Crisan-Dabija, R. A. (2019). Impact of halotherapy on COPD exacerbations: Eur Respiratory Soc. Sehl, J., O’Doherty, J., O’Connor, R., O’Sullivan, B., & O’Regan, A. (2018). Adherence to COPD management guidelines in general practice? A review of the literature. Irish Journal of Medical Science (1971-), 187 , 403-407. Sekine, Y., Katsura, H., Koh, E., Hiroshima, K., & Fujisawa, T. (2012). Early detection of COPD is important for lung cancer surveillance. European Respiratory Journal, 39 (5), 1230-1240. Sen, E., Guclu, S. Z., Kibar, I., Ocal, U., Yilmaz, V., Celik, O., . . . Tereci, H. (2015). Adherence to GOLD guideline treatment recommendations among pulmonologists in Turkey. International journal of chronic obstructive pulmonary disease , 2657-2663. Sharif, R., Cuevas, C. R., Wang, Y., Arora, M., & Sharma, G. (2013). Guideline adherence in management of stable chronic obstructive pulmonary disease. Respiratory medicine, 107 (7), 1046-1052. Singh, S., Loke, Y. K., & Furberg, C. D. (2008). Inhaled anticholinergics and risk of major adverse cardiovascular events in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis. Jama, 300 (12), 1439-1450. Stafyla, E., Kotsiou, O. S., Deskata, K., & Gourgoulianis, K. I. (2018). Missed diagnosis and overtreatment of COPD among smoking primary care population in Central Greece: old problems persist. International journal of chronic obstructive pulmonary disease , 487-498. Surani, S., Aiyer, A., Eikermann, S., Murphy, T., Anand, P., Varon, J., . . . Guzman, A. (2019). Adoption and adherence to chronic obstructive pulmonary disease GOLD guidelines in a primary care setting. SAGE Open Medicine, 7 , 2050312119842221. Tashkin, D. P., Celli, B., Senn, S., Burkhart, D., Kesten, S., Menjoge, S., & Decramer, M. (2008). A 4-year trial of tiotropium in chronic obstructive pulmonary disease. New England Journal of Medicine, 359 (15), 1543-1554. Turan, O., Emre, J. C., Deniz, S., Baysak, A., Turan, P. A., & Mirici, A. (2016). Adherence to current COPD guidelines in Turkey. Expert Opinion on Pharmacotherapy, 17 (2), 153-158. Ulmeanu, R., Mihaltan, F., Arghir, O., Mladinescu, O., & Teodorescu, G. (2016). Treatment goals in COPD: the concordance between patients and physicians (interim results of ACORD study). Chest, 150 (4), 873A. Vogelmeier, C. F., Criner, G. J., Martinez, F. J., Anzueto, A., Barnes, P. J., Bourbeau, J., . . . Fabbri, L. M. (2017). Global strategy for the diagnosis, management, and prevention of chronic obstructive lung disease 2017 report. GOLD executive summary. American Journal of Respiratory and Critical Care Medicine, 195 (5), 557-582. Wei, Y.-F., Kuo, P.-H., Tsai, Y.-H., Tao, C.-W., Cheng, S.-L., Lee, C.-H., . . . Hsu, J.-Y. (2015). Factors associated with the prescription of inhaled corticosteroids in GOLD group A and B patients with COPD–subgroup analysis of the Taiwan obstructive lung disease cohort. International journal of chronic obstructive pulmonary disease , 1951-1956. White, P., Thornton, H., Pinnock, H., Georgopoulou, S., & Booth, H. P. (2013). Overtreatment of COPD with inhaled corticosteroids-implications for safety and costs: cross-sectional observational study. PloS one, 8 (10), e75221. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4227068","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":288839880,"identity":"4926b614-865f-4ffe-9f0e-89e4f348403b","order_by":0,"name":"Hafsa Kanwal","email":"","orcid":"","institution":"Quaid-i-Azam University","correspondingAuthor":false,"prefix":"","firstName":"Hafsa","middleName":"","lastName":"Kanwal","suffix":""},{"id":288839881,"identity":"959aad78-d0be-4597-9d97-4c3c342b00b0","order_by":1,"name":"Amjad Khan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA80lEQVRIiWNgGAWjYHCCBAaeAwcYGNgbwDxGIMVMpBaeA8RrYYBokUggUgv/tAMPP7w5c0feXPLxxs88DDayGw7wHjbAp0XidkKy5Jwbzwx3zk4rluZhSDPecIAvOQGvNbcTEqR5Phxm3HA7xwCo5XDihgM8xgfw6ZAH2vIbqMV+w80zxr95GP4T1mJwOyFNmucG0PAbPGZAWw6AteB1mCFQi+WcM4eTN5xJK7OcY5BsPPMwXzJe78vdzkm+8ebYYdsNxw9vvvGmwk6273jvYQl8WoCRAneFARgxMPPg1wBMKAeQtEAMIaRlFIyCUTAKRhgAALCrVlM/SzPuAAAAAElFTkSuQmCC","orcid":"","institution":"Quaid-i-Azam University","correspondingAuthor":true,"prefix":"","firstName":"Amjad","middleName":"","lastName":"Khan","suffix":""},{"id":288839882,"identity":"d5e426d3-fbe0-4a5a-951c-95ad58e6050a","order_by":2,"name":"Umm-e- Kalsoom","email":"","orcid":"","institution":"Quaid-i-Azam University","correspondingAuthor":false,"prefix":"","firstName":"Umm-e-","middleName":"","lastName":"Kalsoom","suffix":""},{"id":288839883,"identity":"c747538d-f280-4a36-a2ac-3014b07cceb7","order_by":3,"name":"Saima Mushtaq","email":"","orcid":"","institution":"Xi’an Jiaotong University","correspondingAuthor":false,"prefix":"","firstName":"Saima","middleName":"","lastName":"Mushtaq","suffix":""},{"id":288839884,"identity":"1402c084-57da-4901-b276-a9ecdf6b882c","order_by":4,"name":"Yusra Habib Khan","email":"","orcid":"","institution":"Jouf University","correspondingAuthor":false,"prefix":"","firstName":"Yusra","middleName":"Habib","lastName":"Khan","suffix":""},{"id":288839888,"identity":"2ac4d2dd-5939-405c-946c-75706c01262c","order_by":5,"name":"Mahwish Rabia","email":"","orcid":"","institution":"Quaid-i-Azam University","correspondingAuthor":false,"prefix":"","firstName":"Mahwish","middleName":"","lastName":"Rabia","suffix":""},{"id":288839889,"identity":"2f920bea-47fc-401b-837f-fbbb60aba601","order_by":6,"name":"Yu Fang","email":"","orcid":"","institution":"Xi’an Jiaotong University","correspondingAuthor":false,"prefix":"","firstName":"Yu","middleName":"","lastName":"Fang","suffix":""}],"badges":[],"createdAt":"2024-04-06 10:59:25","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4227068/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4227068/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":54446520,"identity":"022cb530-af82-4b6a-86c1-1e57f75b222c","added_by":"auto","created_at":"2024-04-10 16:21:51","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":170470,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4227068/v1/664a6895abdfa11cd5028258.jpg"},{"id":54446541,"identity":"2e5b41b8-fd0f-4f78-aa7c-f9f75aa6da8c","added_by":"auto","created_at":"2024-04-10 16:21:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":541771,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4227068/v1/eeac9b91-fd84-4ac5-9c9e-7903869bf0e5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"An evaluation of Chronic Obstructive Pulmonary Disease (COPD) management within the healthcare System of Pakistan: Insights from a Cross-Sectional analysis of GOLD Guidelines implementation","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCOPD has emerged as a significant global public health concern. Despite recent advancements in healthcare systems worldwide, COPD continues to be a prominent cause of both morbidity and mortality (Vogelmeier et al., \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). COPD is a condition that necessitates frequent visits by patients to healthcare facilities and physicians for their routine follow-up appointments. In 2001, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) was established to enhance the diagnosis, management, and prevention of COPD while also devising strategies to enhance treatment outcomes for individuals with COPD. Annually, a new report is compiled through a comprehensive review of published research, with the overarching aim of improving the practices of healthcare providers in COPD management. These GOLD reports are considered indispensable, evidence-based reference materials, serving as the current guidelines for the care of individuals with COPD (Patel, Patel, Singh, Singh, \u0026amp; Khawaja, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2019\u003c/span\u003e), globally, from 2006 onward, there has been a consistent downward trend in COPD mortality rates, and it is projected that these rates will decrease by 21% by the year 2040 (Gayle, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). The GOLD guidelines were first introduced in 2011 with the primary objective of offering healthcare providers the most pertinent recommendations for diagnosing and managing COPD patients. Subsequently, significant revisions were made to this handbook in 2006, 2011, 2017, and 2021, with additional minor updates occurring on an almost annual basis. Over time, these guidelines have evolved into an indispensable tool widely utilized in global clinical practices (Albitar \u0026amp; Iyer, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Gupta, Malhotra, \u0026amp; Ish, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe 2017 version was particular significance as it improved upon the previous ABCD assessment by incorporating patient symptoms and exacerbation history, while no longer relying on spirometry grading. In contrast, the 2021 guidelines introduced certain adjustments in the recommendations for pharmacological treatment and introduced a new chapter addressing COVID-19-related considerations (Ardelean et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2012\u003c/span\u003e;Cojocaru, Marian, \u0026amp; Cojocaru, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Han et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Despite the recognized importance of COPD guidelines for managing the disease across diverse regions, healthcare practitioners responsible for treating various patient demographics have demonstrated suboptimal levels of adherence to these guideline recommendations (Aissa et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Corrado \u0026amp; Rossi, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Ding, Small, \u0026amp; Holmgren, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Hsieh et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Kim et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Palmiotti et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Rajnoveanu et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Sen et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Sharif, Cuevas, Wang, Arora, \u0026amp; Sharma, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Turan et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2016\u003c/span\u003e), specifically over-treating the patients by prescribing the inhaled corticosteroids (ICS)(Palmiotti et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). The World Health Organization (WHO) notes that the determinants of physicians' adherence to guidelines, particularly those specializing in pulmonology, are highly intricate and encompass not only the healthcare provider but also factors related to the patient, the disease itself, and various social factors (Aissa et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Ulmeanu, Mihaltan, Arghir, Mladinescu, \u0026amp; Teodorescu, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Regardless of the obstacles encountered, inadequate adherence has a detrimental impact on patients' clinical outcomes, heightening the risk of unforeseen acute exacerbations of COPD, and positive treatment outcomes (Hogea et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Sandu, Mihaescu, Filipeanu, Cernomaz, \u0026amp; Crisan-Dabija, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2019\u003c/span\u003e)(Aissa et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Improved adherence, on the other hand, has clinical and functional benefits as well as economic benefits that reduce direct and indirect healthcare expenditures (Asche et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Chan et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Chiang, Liu, Chuang, \u0026amp; Jheng, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Miravitlles et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Sen et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2015\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e The majority of researches on physician adherence to the GOLD guidelines have been undertaken at multiple levels\u0026mdash;regional, and international. (Asche et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Cojocaru et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Duarte-de-Ara\u0026uacute;jo, Teixeira, Hespanhol, \u0026amp; Correia-de-Sousa, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Hsieh et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Kim et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Palmiotti et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Sandu et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Sen et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Vogelmeier et al., \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2017\u003c/span\u003e),still there is no study to assess the adherence to GOLD guidelines has been conducted in Pakistan. Due to the highest variability in study results (Gupta et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Sehl, O\u0026rsquo;Doherty, O\u0026rsquo;Connor, O\u0026rsquo;Sullivan, \u0026amp; O\u0026rsquo;Regan, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) it is impossible to extrapolate the study results to Pakistan. These studies have been conducted not only among pulmonologists, but also among specialists involved in COPD treatment (Surani et al., \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2019\u003c/span\u003e), for the assessment of different GOLD guidelines (Palmiotti et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). A study emphasized the relevance of improving recommendations' implementation in healthcare settings by streamlining their dissemination (Sen et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Enhanced collaboration between healthcare professionals and policy-making entities responsible for guideline implementation is essential. This collaboration aims to identify barriers to adherence and tailor recommendations to align with the practical needs of everyday healthcare delivery (Ardelean et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). Considering these observations, it was valuable to assess the extent of pulmonologists' familiarity with and utilization of COPD management guidelines in Pakistan. This assessment is particularly pertinent given that a 2019 study estimated the overall prevalence of this condition at 2.1% within the adult population in the country (Khan et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe present study has exclusively concentrated on the practices of physicians pertaining to COPD management.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eAim\u003c/strong\u003e: The study's primary objectives encompass the following: (1) assess prevailing pharmacological prescription practices for COPD treatment aligned with the 2021 GOLD guidelines, (2) ascertain the extent of adherence among pulmonologists, and (3) identify potential factors that may exert influence on adherence to therapeutic guidelines.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Design and Study Setting\u003c/strong\u003e: This cross sectional observational study was conducted from April 1st to September 30th, 2022, across various healthcare facilities in the twin cities of Pakistan. The study involved the collection of outpatient prescriptions and comprehensive medical records. \u003cstrong\u003eStudy Participants\u003c/strong\u003e: Inclusion criteria encompassed patients meeting the following criteria: a documented diagnosis of COPD confirmed by a pulmonologist through clinical history, physical examination, and spirometric assessment; a stable form of the condition; age equal to or greater than 40 years; and classification into the ABCD risk groups based on symptoms and exacerbation history according to the 2021 GOLD guidelines. Exclusion criteria comprised of inpatients, individuals younger than 40 years of age, those lacking a confirmed COPD diagnosis, incomplete medical records (specifically, the absence of GOLD stage/group information), and patients presenting with acute COPD exacerbations or concurrent asthma diagnoses.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection\u003c/strong\u003e: Each patient was assigned a unique reference number corresponding to their inclusion sequence within the study. The following data points were gathered: age, gender, residential location (categorized as urban or rural), smoking history, and spirometry-based classification of airflow limitation severity, spanning from GOLD Grades 1 to 4. Symptom assessment was conducted using the COPD Assessment Test (CAT), while the level of breathlessness was measured utilizing the Modified British Medical Research Council (mMRC) Questionnaire. Subsequently, based on their CAT and mMRC scores, patients were categorized into the ABCD groups. Groups A and B, characterized by lower exacerbation rates in comparison to C and D, are deemed as the low-risk categories, whereas C and D represent the high-risk groups with a higher likelihood of exacerbation (Rajnoveanu et al., \u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e). Comorbidities (cardiovascular diseases), the presence of a chronic respiratory failure diagnosis in the patient medical records, first consultation or regular follow-up visit, inhaled pharmacological medications prescribed for COPD as a monotherapy or in different combinations of short-acting beta agonists (SABA), long-acting beta agonists (LABA), short-acting antimuscarinic agents (SAMA), long-acting antimuscarinic agents (LAMA), and inhaled corticosteroids (ICS). Comorbid cardiovascular disease consists of arterial hypertension, ischemic heart disease, heart failure, arrhythmias, and valvopathies, as they were mentioned in the patients\u0026rsquo; medical records.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAssessment Criteria for Adherence to the GOLD Guidelines\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAdherence was characterized as suitable when the prescribed pharmacological therapy aligned with the guidelines, either as the primary or alternative medication option, while it was considered inappropriate if it did not adhere to these recommendations. Furthermore, inappropriate therapy was categorized as either overtreatment or under-treatment. The evaluation of suitable therapy was carried out in accordance with the dedicated 2021 GOLD algorithms specific to the treatment of each risk group (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eTreatment algorithm according to the GOLD guidelines 2021\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eAppropriateness ( Concordance with the GOLD guidelines\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eInappropriateness (Discordance with the GOLD guidelines)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGroup\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eFirst Choice\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eAlternative Choice\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eUnder-treatment\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eOver-treatment\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eA\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eA bronchodilator\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eChange the bronchodilator\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo bronchodilator prescribed\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLABA\u0026thinsp;+\u0026thinsp;LAMA, ICS or any combination treatment\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eB\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLAMA or LABA\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLAMA\u0026thinsp;+\u0026thinsp;LABA\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOnly short-acting bronchodilator\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLAMA\u0026thinsp;+\u0026thinsp;LABA\u0026thinsp;+\u0026thinsp;ICS, ICS\u0026thinsp;+\u0026thinsp;LABA, ICS\u0026thinsp;+\u0026thinsp;LAMA\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eC\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLAMA\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLAMA\u0026thinsp;+\u0026thinsp;LABA or ICS\u0026thinsp;+\u0026thinsp;LABA\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOnly ICS or LABA or SABA\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eICS\u0026thinsp;+\u0026thinsp;LAMA, ICS\u0026thinsp;+\u0026thinsp;LABA\u0026thinsp;+\u0026thinsp;LAMA\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eD\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLAMA\u0026thinsp;+\u0026thinsp;LABA or LAMA or ICS\u0026thinsp;+\u0026thinsp;LABA\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eIf still exacerbation resent ICS\u0026thinsp;+\u0026thinsp;LABA\u0026thinsp;+\u0026thinsp;LAMA\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOnly ICS or SABA or LABA, ICS\u0026thinsp;+\u0026thinsp;LAMA\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData collection was initially conducted in Microsoft Excel software, and subsequently was imported into SPSS software (IBM SPSS Statistics 25.0) for comprehensive statistical analysis. Quantitative variables were represented as either the median, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD), or with a 95% confidence interval (CI). Qualitative variables were presented in terms of absolute figures and relative percentages. Statistical analyses involved the utilization of the chi-squared test to compare frequencies, while the t-test for independent samples was employed to compare means between two sets of normally distributed variables. The threshold for statistical significance was established at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe study encompassed a total of 182 patients who sought consultations from nine different pulmonologists. A pool of 294 patients was excluded from the analysis due to the absence of documented COPD stage/group information, incomplete records regarding smoking history, and insufficient disease history details. Nevertheless, even within the included patient cohort, some data were missing. Although all the data were retrospective, certain components such as the CAT and mMRC questionnaires were administered during the study to categorize patients into the ABCD groups. Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e presents the baseline characteristics of the COPD patients. The mean age of the study participants was 61.16 years, with a standard deviation of 11.004 years. Male patients constituted the majority at 73.6%, while females accounted for 26.4%. All patients were of Asian Pakistani origin (100%), with 102 (56.0%) residing in urban areas and 80 (44.0%) in rural locales. Among the 182 patients, smoking history data were available for 97 individuals, representing 53.29% of the sample, and of these, only 76 patients had recorded smoking pack-years, with an average of 52\u0026thinsp;\u0026plusmn;\u0026thinsp;12.26 pack years.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eDemographic characteristics of Chronic Obstructive Pulmonary Disease (COPD) patients\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eDemographics\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (Mean (SD))\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e61.16(11.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e134(73.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48(26.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eResidency, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e102(56.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e80(44)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSmoking history, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCurrently doing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e61(33.51)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQuit smoking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e97(53.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo smoking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24 (13.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSpirometric GOLD grade, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGold 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24(22.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGold 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45(42.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGold 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17(16.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGold 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20(18.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGOLD group, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGRADE A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41(22.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGRADE B\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e75(41.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGRADE C\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40(22.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGRADE D\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26(14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCardiovascular co-morbidity, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e85(46.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e97(53.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eAccording to the GOLD spirometry grades, 41.2% of the patients fell under GOLD 2. When classified using symptoms and a history of acute exacerbations to determine the refined 2021 GOLD ABCD groups, the majority of patients were categorized into Group B (41.2%). Among current smokers, Group A and Group B were the most prevalent, at 30.0% and 22.24%, respectively. Cardiovascular co-morbidities were present in 46.7% of COPD patients, but data regarding chronic respiratory failure were not available.\u003c/p\u003e\n\u003cp\u003eThe distribution of therapeutic regimens varied among the GOLD ABCD groups, as detailed in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e. In general, the most frequently prescribed maintenance treatment was the combination of LAMA, accounting for 27.5%, followed by LAMA\u0026thinsp;+\u0026thinsp;LABA combination therapy (administered through separate inhalers) at 21.4%, standalone LAMA therapy at 17.0%, and LABA\u0026thinsp;+\u0026thinsp;ICS combination therapy at 13.7%.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eMedications used by the COPD patients for the disease management according to ABCD classification\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd colspan=\"4\" align=\"left\"\u003e\n \u003cp\u003eGOLD classification\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade A\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade B\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade C\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade D\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"8\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTreatment Regimen\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eIn COPD patients\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSABA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2(4.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6(8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10(5.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLABA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16(39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26(34.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6(15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2(7.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50(27.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLAMA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10(24.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13(17.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5(12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3(11.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31(17)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLAMA\u0026thinsp;+\u0026thinsp;LABA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8(19.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22(29.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7(17.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2(7.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39(21.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eICS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2(2.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2(1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLAMA\u0026thinsp;+\u0026thinsp;ICS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7(17.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4(15.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11(6.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLABA\u0026thinsp;+\u0026thinsp;ICS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3(7.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6(8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7(17.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5(19.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25(13.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLAMA\u0026thinsp;+\u0026thinsp;LABA\u0026thinsp;+\u0026thinsp;ICS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8(20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10(38.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18(9.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eOut of the initial 182 patients meeting the inclusion criteria, 100 individuals (54.90%) received the appropriate therapy, demonstrating a 54.90% adherence rate to the GOLD guidelines. The suitability and inappropriateness of pharmacological treatments exhibited variations among each of the ABCD groups (Fig.\u0026nbsp;1).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eFrequency distribution of under\u0026minus;treatment and over\u0026minus;treatment in ABCD groups in patients receiving inappropriate treatment\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth colspan=\"2\" rowspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eTreatment\u003c/p\u003e\n \u003c/th\u003e\n \u003cth rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eInappropriate treatment\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eUnder treatment\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOver treatment\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" align=\"left\"\u003e\n \u003cp\u003eGOLD Classification\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGRADE A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGRADE B\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGRADE C\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGRADE D\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e32\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e51\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e83\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e, the most inappropriate therapy was observed among patients in Group A, with 43.9% of cases falling into this category. This group exhibited overtreatment in 56.09% of instances, with 24.4% receiving LAMA, 19.5% receiving LAMA\u0026thinsp;+\u0026thinsp;LABA, and 7.3% receiving LABA\u0026thinsp;+\u0026thinsp;ICS, while under-treatment was identified in 4.9% of patients who did not receive a disease-specific treatment.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab5\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eTreatment appropriateness and inappropriateness among the low risk groups A and B and high risk groups C and D\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAppropriate\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;101)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eIn Appropriate\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;81)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eIndependent Sample Test-Statistics\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge(Mean, SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e60.01(11.207)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e62.59(10.642)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003et=-1.580\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.116\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e69(68.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e65(80.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({\\chi }^{2}\\)\u003c/span\u003e\u003c/span\u003e=5.295\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.023\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32(31.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16(19.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eResidence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eUrban\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e62(61.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40(49.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({\\chi }^{2}\\)\u003c/span\u003e\u003c/span\u003e=2.629\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.105\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eRural\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39(38.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41(50.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCardiovascular comorbidities\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39(38.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46(56.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({\\chi }^{2}\\)\u003c/span\u003e\u003c/span\u003e=5.966\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.015\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e62(61.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35(43.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroups A and B (n) vs. Groups C and D (n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e66 vs 35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50 vs 31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({\\chi }^{2}\\)\u003c/span\u003e\u003c/span\u003e=.255\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.614\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" align=\"left\"\u003e\n \u003cp\u003eGroups A and B (n) vs. Groups C and D (n)\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eOdd ratio\u0026thinsp;=\u0026thinsp;1.169 (95% CI, .637-2.146)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eCardiovascular comorbidities to with and without appropriateness:\u003c/p\u003e\n \u003cp\u003eOdd ratio\u0026thinsp;=\u0026thinsp;\u003cstrong\u003e.479 (95% CI, .264-.868)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eAmong Group C patients, 47.5% received inappropriate (overtreatment) prescriptions, predominantly with LABA\u0026thinsp;+\u0026thinsp;ICS (17.5%) and LABA\u0026thinsp;+\u0026thinsp;LAMA\u0026thinsp;+\u0026thinsp;ICS (20.0%), whereas under-treatment was observed with LABA (15.0%). In Group D patients, 46.15% were treated inappropriately, with under-treatment seen in 7.7% for LABA, 11.5% for LAMA, 7.7% for LAMA\u0026thinsp;+\u0026thinsp;LABA, and 19.23% for LABA\u0026thinsp;+\u0026thinsp;ICS. Notably, ICS overprescription occurred in 23% of cases, either as a sole therapy or in combination. Chi-squared test was conducted to examine the inappropriateness of prescriptions between the high-risk exacerbation groups (C and D), which were recommended by the GOLD 2021 guidelines, in comparison to the low-risk exacerbation groups (A and B). The results did not show statistical significance (p\u0026thinsp;=\u0026thinsp;0.614), indicating a consistent trend of inappropriateness across all the ABCD groups. Patients in Groups C and D had an odds ratio (OR) of 1.169 with a 95% confidence interval (CI-0.637-2.146), suggesting a similar pattern of inappropriateness among all ABCD groups. The frequency of treatment concordance recorded statistically significant differences between patients with and without cardiovascular comorbidities (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.015), with an OR of .479 (95% CI, .264-.868)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ePrevious research revealed that device preference, insufficient symptom evaluation, pulmonologist carelessness, and optimism for steroid effectiveness were associated with low adherence to the GOLD standards (Chan et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Turan et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; White, Thornton, Pinnock, Georgopoulou, \u0026amp; Booth, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2013\u003c/span\u003e) that was also same in our observation. Our study noted that these observations remained consistent, with spirometry still being the least frequently utilized device. Initially, out of a pool of 478 patients, only 182 underwent spirometry testing, signifying a spirometry utilization rate of 38.49%, and a majority of these tests were conducted in private clinics. Additionally, for the purpose of ABCD classification, we introduced the practice of administering CAT and mMRC assessments ourselves, which had not been previously implemented within our study sample or in healthcare practices elsewhere. The core findings of our research were the showed comparatively less adherence of healthcare practitioners to the 2021 GOLD guidelines (54.90%), that was quite similar to the following study (White et al., \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2013\u003c/span\u003e) having (58.1%) adherence to GOLD guidelines. A Turkish study showed that only 40.4% of COPD patients received GOLD guideline-concordant treatments(Turan et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2016\u003c/span\u003e).The association between inappropriate treatment prescriptions and comorbid cardiovascular disease (.479 higher risk). LABA containing regimen either alone or in combination was the most prescribed drug according to our study with (72.5%).\u003c/p\u003e \u003cp\u003e The primary aim of this study was to evaluate the compliance of pulmonologists and general practitioners with the recently updated GOLD guidelines. Adherence to healthcare guidelines is defined by the US National Library of Medicine as \"conformity in fulfilling or following official, established guidelines, recommendations, protocols\" when applying them within the clinical setting (medicines). While grasping the concept of adherence to guidelines is straightforward, the actual execution can be challenging (L\u0026oacute;pez-Campos, Quintana Gallego, \u0026amp; Carrasco Hern\u0026aacute;ndez, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Numerous studies conducted across various regions and states worldwide have employed similar metrics to gauge the adherence of healthcare practitioners to the current GOLD guidelines (Chinai, Hunter, \u0026amp; Roy, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Duarte-de-Ara\u0026uacute;jo et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Hsieh et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Kim et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Palmiotti et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Patel et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Sharif et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Turan et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) to the metrics we use in our study. In present study the overall adherence to the recent GOLD guidelines was 54.90% that was similar to the study conducted in western Europe and USA where adherence to the guidelines was 58.25%(Ding et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) and higher comparing to the most of the previously published studies i.e. 49.6% in South Korea (Kim et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2019\u003c/span\u003e), 44.9% in Taiwan the capital of Iran (Chiang et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2013\u003c/span\u003e) 29.7% in Tunisia and the Maghreb (probably the lowest adherence level to the GOLD guidelines(Vogelmeier et al., \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). However, some studies reported higher level of adherence than our study results included 61.6% in Turkey (Martins et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), 70% reported by Palmiotti and coworkers and 79.02% by Rajnoveanu and his team(Chinai et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) Although there is no limit of percent adherence to guidelines, it is continuous process that can be improved (Chan et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe demographic and clinical characteristics of our study population closely resembled those observed in other studies. Specifically, our cohort consisted of 184 COPD patients, which was lower than the sample size of 296 in the study conducted by Aissa et al. and larger than the study conducted by Chinai and colleagues, which had a sample size of 154, respectively (Aissa et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Chinai et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). As is the case in numerous other studies within this field, males constituted the majority at 73.6% (Aissa et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Duarte-de-Ara\u0026uacute;jo et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Hsieh et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Kim et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Palmiotti et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2018\u003c/span\u003e), while the mean age was lower than the previously conducted studies (Kim et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Patel et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). In terms of smoking status, the outcomes of our study closely paralleled those reported in studies conducted in Italy and Romania, respectively (Miravitlles et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Rajnoveanu et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). However, the proportion of current smokers among COPD patients, at 23.0%, was concerning. This suggests a potential deficiency in tobacco treatment programs, as well as a lack of active smoking cessation campaigns or counseling efforts in Pakistan (Martins et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAccording to the present study, the adherence rate was different in all the COPD groups ABCD, higher level of appropriateness was seen 75% in low risk exacerbation risk B group followed by high risk exacerbation groups C and D where level of adherence was 52.5% and 53.84% respectively. Low level of adherence was observed 43.9% in Group A showing consistency with other studies (Martins et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Palmiotti et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Turan et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Vogelmeier et al., \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2017\u003c/span\u003e), emphasized that COPD patients from this GOLD Groups and from various countries are not being treated adequately by the medical professionals (Patel et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Taken together, each ABCD group displayed a similar propensity to receive inappropriate treatment. However, groups A and B exhibited a 1.169-fold higher likelihood of receiving inappropriate treatment compared to those in groups C and D (p\u0026thinsp;=\u0026thinsp;0.614). These findings underscore the importance of healthcare practitioners consulting the GOLD guidelines when prescribing for patients in both the low-risk groups A and B, as well as the high-risk groups C and D, in accordance with the guideline recommendations. It's worth noting that the majority of patients treated in healthcare settings belonged to group B, comprising 75 individuals (41.2%), consistent with findings from previous studies (Chiang et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Palmiotti et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Vogelmeier et al., \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) and adherence rate was also higher in this group contrary to the previous studies(Chan et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Ding et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Regarding the findings of our study, a notable observation pertains to the prevalence of overtreatment, with the highest occurrence observed in group A, where patients typically require fewer medications. Conversely, it's worth highlighting that no cases of overtreatment were identified in GOLD Group D, aligning with similar findings reported in this study (Asche et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). These findings can likely be attributed to the fact that patients falling into this category, characterized by a substantial symptom burden and a heightened risk of exacerbation, typically receive maximal therapy (LAMA\u0026thinsp;+\u0026thinsp;LABA\u0026thinsp;+\u0026thinsp;ICS) in the event of further exacerbations. Consequently, there is minimal possibility of overtreatment in this group (Ray et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Vogelmeier et al., \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e The presence of cardiovascular comorbidities emerged as another pivotal factor influencing the alignment of therapeutic prescriptions with guideline recommendations. Among COPD patients, the most prevalent concurrent conditions included cardiovascular ailments, lung cancer, obstructive sleep apnea, as well as anxiety and depression (Budin et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Jimborean et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Rabe, Hurst, \u0026amp; Suissa, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Sekine, Katsura, Koh, Hiroshima, \u0026amp; Fujisawa, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). These coexisting medical conditions can exert an influence on health status, disease advancement, and prognosis (Budin et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Roughly half of the participants in our study, approximately 46.7%, exhibited cardiovascular comorbidities. This comorbidity significantly affected the adherence of pulmonologists to the GOLD criteria. A prior study conducted by Sharif et al. had also noted a heightened prevalence of cardiovascular comorbidities in COPD patients (Sharif et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). Nonetheless, the outcomes of our study revealed a statistically significant variation in adherence among patients with cardiovascular comorbidities (p\u0026thinsp;=\u0026thinsp;0.015). These findings underscore the importance of increasing healthcare practitioners' vigilance not only in identifying comorbidities but also in exercising greater caution when prescribing treatments for COPD in patients with concurrent cardiovascular diseases. It's imperative to recognize that therapies for one condition may impact the other, underscoring the critical need for appropriate treatment strategies addressing both conditions (Rabe et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAmong COPD patients with cardiovascular issues, inappropriate treatments encompassed both under- and over treatment. Under-treatment might be attributed to prior apprehensions regarding an elevated risk of cardiovascular events associated with the initial use of LAMA and LABA medications. This concern persisted despite the generally favorable safety profile of these long-standing medications (Rabe et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). The safety of bronchodilators may pose a concern in cases of over-treatment. Nevertheless, there exists inconclusive evidence regarding the association between bronchodilator usage and cardiovascular events in COPD patients. Certain studies have indicated a heightened risk of cardiovascular events associated with bronchodilator use, whereas others have found no evidence of such a risk. Additionally, some studies have even suggested a reduction in risk among COPD patients using bronchodilators (Calverley et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Gershon et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Singh, Loke, \u0026amp; Furberg, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2008\u003c/span\u003e; Tashkin et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2008\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eIn the current study, LABA therapy was the most frequently prescribed, accounting for 27.5%, and LABA\u0026thinsp;+\u0026thinsp;LAMA was the second most commonly prescribed therapy, representing 21.4% of cases. This contrasts with findings from other studies where the most commonly prescribed therapeutic regimen was LAMA\u0026thinsp;+\u0026thinsp;LABA (Rajnoveanu et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Turan et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2016\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAccording to the results of the current study, ICS was notably less commonly prescribed, either as a standalone therapy or in combination regimens. However, the incidence of overtreatment with ICS in groups A and B was 18%, which closely resembled the findings of a prior study where overtreatment with ICS was observed at a rate of 17.81%. This outcome was surprising since previous studies had identified ICS as the most prevalent type of inappropriateness (Palmiotti et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Petite, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Price et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Sen et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Stafyla, Kotsiou, Deskata, \u0026amp; Gourgoulianis, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). GOLD guidelines recommend the use of ICS in patients with a history of exacerbations (Group C and D), but not in those without such a history (Group A and B). Although there was no significant use of ICS observed in the low-risk groups, a small percentage of patients were prescribed ICS in Group A (7.3%) and Group B (10.2%), either as a single therapy or in combination. This prescribing pattern contradicts the findings typically reported in studies such as the TOLD study, the KOCOSS study, and the Portuguese study conducted by Duarte-de-Araujo (Hsieh et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Kim et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Ulmeanu et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Wei et al., \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Furthermore, an examination of the local context might shed light on additional factors contributing to the persistent overtreatment of individuals with lower GOLD grades. In the local market, the availability of a sole LABA medication, coupled with the discontinuation of LABA and LABA\u0026thinsp;+\u0026thinsp;LAMA options in drug stores, resulted in an increased tendency to prescribe the ICS\u0026thinsp;+\u0026thinsp;LABA combination. The male gender was linked to a heightened likelihood of receiving inappropriate therapy. Interpretation of these findings is challenging due to the limited data available in the literature concerning such outcomes, highlighting the necessity for additional research in this area. Notably, our study, to the best of our knowledge, represents the first investigation in Pakistan to address the issue of pulmonologist adherence to the GOLD 2017 guidelines, which is a notable strength. Additionally, the inclusion of patients with cardiovascular disease, a group typically excluded from controlled trials, is another noteworthy aspect of our study. Certainly, our research is subject to certain limitations. Firstly, given that this study was conducted within a single region and with a relatively small sample size, it is important to exercise caution when generalizing the findings to other regions of the country. Secondly, as COPD patients are still underdiagnosed or not consistently categorized according to GOLD risk groups, the study's design, which encompassed all patients classified within the ABCD categories, may not fully mirror real-world scenarios. The presence of a substantial number of ineligible patients, lacking COPD stage/group indications in their records, might potentially lead to an overestimation of pulmonologist adherence. Another drawback is the absence of patient follow-up data, which means there is no available evidence regarding the long-term management of stable COPD. Moreover, it's important to note that the current study does not provide insights into adherence to non-pharmacological treatments or the utilization of alternative pharmacological medications. Additionally, the study did not examine various pivotal practical factors, including the accessibility and affordability of pharmaceuticals. Given that the healthcare system lacks a centralized body responsible for covering treatment costs, these factors can significantly influence medication prescription practices, potentially accounting for deviations among pulmonologists from guideline recommendations.\u003c/p\u003e \u003cp\u003eIn conclusion, based on our findings, we offer several recommendations that could prove beneficial for clinical practice in Pakistan. First and foremost, there is a pressing need for a more appropriate implementation of COPD guidelines, commencing with an accurate and comprehensive diagnosis that subsequently guides appropriate therapy. Furthermore, healthcare professionals across the board should pay special attention to patients falling within low-risk Groups A and B, as well as those who present with concurrent cardiovascular conditions.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eOur research has identified that the adherence of pulmonologists to the GOLD criteria falls short of the desired level and warrants improvement. Notably, the presence of cardiovascular comorbidities and the inclusion of patients in the low-risk categories (A and B) emerge as pivotal factors influencing the appropriateness of COPD treatment. Furthermore, it is noteworthy that even among individuals at low risk of exacerbation, the most prevalent form of over treatment involves regimens containing inhaled corticosteroids (ICS). To bridge the disparity between guideline recommendations and real-world clinical practice, it is imperative to conduct additional multicenter studies encompassing all potential factors that may impact adherence rates.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eGOLD: Guidelines for Chronic Obstructive Lung Disease\u003c/p\u003e\n\u003cp\u003eICS: Inhaled corticosteroid\u003c/p\u003e\n\u003cp\u003eCAT: COPD assessment test\u003c/p\u003e\n\u003cp\u003eCOPD: Chronic obstructive pulmonary disease\u003c/p\u003e\n\u003cp\u003ePFT: Pulmonary function test\u003c/p\u003e\n\u003cp\u003eSPSS: Statistical Package for the Social Sciences\u003c/p\u003e\n\u003cp\u003eFEV1: Forced expiratory volume in one second\u003c/p\u003e\n\u003cp\u003eFVC : Forced vital capacity\u003c/p\u003e\n\u003cp\u003eLABA: Long-acting \u0026beta;\u003csub\u003e2\u003c/sub\u003e agonist\u003c/p\u003e\n\u003cp\u003eSABA: Short-acting \u0026beta;\u003csub\u003e2\u003c/sub\u003e agonist\u003c/p\u003e\n\u003cp\u003eLAMA: Long-acting muscarinic antagonist\u003c/p\u003e\n\u003cp\u003eSAMA: Short-acting muscarinic antagonists\u003c/p\u003e\n\u003cp\u003emMRC: Modified Medical Research Council\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval\u003c/h2\u003e\n\u003cp\u003eThe study was approved by the bio-ethical committee of Quaid-i-Azam University, Islamabad, Pakistan, under the No. #BEC-FBS-QAU2021-269 and from the study site i.e. Holy Family Hospital, Rawalpindi, Pakistan, under the Ref. No.63/IREF/RMU/2021.\u003c/p\u003e\n\u003ch2\u003eConsent to participate\u003c/h2\u003e\n\u003cp\u003eA signed consent was obtained from every participant during the study by the principle investigator.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eN/A\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eN/A\u003c/p\u003e\n\u003ch2\u003eAcknowledgement\u003c/h2\u003e\n\u003cp\u003eWe are thankful to the Higher Education Commission (HEC), Pakistan for providing a grant under the National Research Program for Universities- NRPU Ref No. 20-14413/NRPU/R\u0026amp;D/HEC/2021.\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eThe datasets utilized or examined in the present study can be obtained upon a reasonable request directed to the corresponding author.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eHafsa K , and Amjad K conceived and designed the study; Hafsa K and Umm E K collected the data and Mahwish R has analyzed the data; Hafsa K and Umm E K, prepared the original draft; Yusra H K and Yu F critically evaluated and finalized the manuscript; all authors approved the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAissa, S., Knaz, A., Maatoug, J., Khedher, A., Benzarti, W., Abdelghani, A., . . . 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Factors associated with the prescription of inhaled corticosteroids in GOLD group A and B patients with COPD\u0026ndash;subgroup analysis of the Taiwan obstructive lung disease cohort. \u003cem\u003eInternational journal of chronic obstructive pulmonary disease\u003c/em\u003e, 1951-1956. \u003c/li\u003e\n\u003cli\u003eWhite, P., Thornton, H., Pinnock, H., Georgopoulou, S., \u0026amp; Booth, H. P. (2013). Overtreatment of COPD with inhaled corticosteroids-implications for safety and costs: cross-sectional observational study. \u003cem\u003ePloS one, 8\u003c/em\u003e(10), e75221. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Adherence to COPD guidelines, adherence to GOLD guidelines, pulmonologist, chronic obstructive pulmonary disease, guidelines, COPD management in developing country, COPD care in Pakistan","lastPublishedDoi":"10.21203/rs.3.rs-4227068/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4227068/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003e Recognizing the significance of standardized treatment guidelines in managing COPD, this study aimed to explore prescription patterns in the treatment of chronic obstructive pulmonary disease (COPD). The primary objectives were to assess the extent to which pulmonologists adhere to these guidelines and to pinpoint any factors that may influence physician adherence.\u003c/p\u003e\u003ch2\u003eMethodology:\u003c/h2\u003e \u003cp\u003eThe research was conducted from April to September 2022 in various healthcare facilities within the twin cities of Pakistan. COPD outpatients were categorized into different risk groups (ABCD) in accordance with the 2021 GOLD strategy. In the context of COPD management, physicians' clinical practices were evaluated by examining both the patients' disease status and the treatment regimens prescribed to determine the degree of adherence to established guidelines.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eThe study included 182 patients, mostly (73.6%) were male with the age mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD 61.16\u0026thinsp;\u0026plusmn;\u0026thinsp;11.004 years. All patients were Asian Pakistani (100%); 102 (56.0%) patients lived in urban areas, and 80 (44.0%) in rural areas. The most prescribed treatment was the combination long-acting beta agonist (LABA) (27.5%), followed by combination therapy LAMA\u0026thinsp;+\u0026thinsp;LABA (in different inhalers) ((21.4%), LAMA (17.0%), and LABA\u0026thinsp;+\u0026thinsp;ICS (13.7%).The most inappropriate therapies were in Group A (56.09%) followed by a7.5% in Group C. Patients with cardiovascular comorbidities had a .479 (95% CI, .264-.868) times higher risk of receiving an inappropriate therapy (p\u0026thinsp;=\u0026thinsp;0.015).\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e \u003cp\u003e Pulmonologist compliance with the GOLD guidelines falls short of the desired level and necessitates enhancement. Among the influential factors contributing to the inadequacy of COPD treatments, cardiovascular comorbidities and the inclusion of low-risk Groups A and B are notable, as they carry an elevated risk of overtreatment. Furthermore, it is noteworthy that LABA, while being the most frequently prescribed therapy, is not aligned with the guideline's recommendations to a substantial extent.\u003c/p\u003e","manuscriptTitle":"An evaluation of Chronic Obstructive Pulmonary Disease (COPD) management within the healthcare System of Pakistan: Insights from a Cross-Sectional analysis of GOLD Guidelines implementation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-10 16:21:39","doi":"10.21203/rs.3.rs-4227068/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7ea62986-e746-4b9c-8b55-bb4a9b61783b","owner":[],"postedDate":"April 10th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-04-10T16:21:39+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-10 16:21:39","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4227068","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4227068","identity":"rs-4227068","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}