Assessment of prescription practices according to international chronic obstructive pulmonary disease guidelines on Egyptian doctors

Background and objectives Chronic obstructive pulmonary disease (COPD) is defined as ‘a preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients’. Its pulmonary component is characterized by airflow limitation that is not fully reversible. There is a wide variation in physicians’ management of the condition, and this may be ascribed to nonadherence to the guidelines. Adherence to COPD guidelines in clinical practice in most countries is not satisfactory. Aim The aim of this work is to assess the prescription pattern and clinical practice attitudes toward Egyptian COPD patients managed by chest physicians and internal medicine physicians in Abbassia Chest Hospital and Ain Shams University Hospitals during the period from February 2013 to January 2014. Patients and methods In this study, one questionnaire was specifically directed to physicians. Sixty doctors were at Abbassia Chest Hospital, 63 at Ain Shams University Hospitals, and six doctors at Ministry Hospitals. Doctors were chest residents (29.5%), chest physicians with masters degree (33.3%), chest physicians with MD (13.2%), or internal medicine doctors (34%). Results Only 53 physicians performed spirometry. Most of the physicians prescribed antibiotics and systemic steroids to their patients in exacerbations. Macrolides, cephalosporins, and quinolones were the most commonly prescribed antibiotics by physicians in COPD exacerbations. Only 46 physicians used noninvasive ventilation in hypercapnic respiratory failure. Only 33 physicians were following GOLD 2013 guidelines. Conclusion Doctors’ awareness of guidelines is suboptimal; major deviations from the GOLD guidelines were in the form of underuse of spirometry, smoke cessation programs, and of noninvasive ventilation in exacerbations and lack of use of pulmonary rehabilitation treatment.


Introduction
In developing countries where smoking continues to be extremely prevalent, the health and economic burdens are higher than in developed nations [1]. Exacerbations contribute to overall disease severity and extrapulmonary effects impact on the cardiovascular, muscular, skeletal systems, and metabolic syndrome [2], contributing to a range of comorbidities such as diabetes [3]. Despite the availability of international guidelines, primary care physicians often manage chronic obstructive pulmonary disease (COPD) in a manner that is discordant with recommendations .Yet even among physicians who have some guideline familiarity, practice patterns are often inconsistent with guideline recommendations [4].

Aim
The purpose of the present study is to assess to what extent the international guidelines differ from the existing practice among Egyptian COPD patients managed by pulmonologists or other physicians.

Patients and methods
One hundred and twenty nine doctors were selected from Abbassia Chest Hospital, Ministry Hospitals, and Ain Shams Univers ity Hospitals during the study period from February 2013 to January 2014. In this study, one questionnaire was specifically directed to physicians. Ain Shams University Hospitals and Abbassia Chest Hospital both are classified as tertiary hospitals according to the Egyptian Ministry of Health Medical System. In this study, doctors were classified into chest residents, chest physicians with masters degree, chest physicians with MD, and internal medicine doctors. In this study, some residents with less than 3 months of clinical practice in residency could not perform the questionnaire because of nonawareness of Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease (GOLD) guidelines; also, some internal medicine doctors refused to have the questionnaire, as they always refer COPD patients to a pulmonologist. Consequently, all those doctors were excluded from this study.
Each doctor who participated in this study was subjected to the following questionnaire: (1) How many patients treated for COPD do you see on average during a normal month of activity in the outpatient clinic? Less than 20 patients; 20-40 patients; more than 40 patients. (2) How many of these patients needed hospitalization? Less than 10 patients; 10-20 patients; more than 20 patients.

Statistical analysis
The collected data were revised, coded, tabulated, and introduced to a PC using statistical package for the social science (SPSS, 15.0.1 for Windows; SPSS Inc., Chicago, Illinois, USA). Data were presented and suitable analysis was done according to the type of data obtained for each parameter.

Descriptive statistics
The descriptive statistics were as follows: (1) Mean±SD, and minimum and maximum values (range) for numerical data. (2) Frequency and percentage of non-numerical data.

Analytical statistics
(1) χ 2 -test was used to examine the relationship between two qualitative variables: (a) P-value: level of significance. (b) P-value greater than 0.05: nonsignificant.

This
Most of the doctors participating were chest physicians with masters degree (33.3%) and chest residents (29.5%), as shown in Table 3. Most of the doctors had less than 4 (48.8%) years of practical experience, as shown in Table 4. Most of the doctors examined between 20 and 40 (52.7%) COPD patients per month in outpatient clinic, as shown in Table 5.
Most of the doctors diagnosed less than 20 (74.7%) new COPD patients per month in the outpatient clinic, as shown in Table 6. Most of the doctors agreed that between 10 and 20 (58.1%) COPD patients who are seen in the outpatient clinic per month needed hospitalization, as shown in Table 7.
Most doctors (75.2%) did not admit smoker COPD patients to smoke cessation programs, and doctors who did were five internists and 27 chest physicians, as shown in Table 8. Most of the doctors (95.3%) did not have a structured educational program. Six (4.7%) doctors (only five chest doctors and one internist) provided a structured education to COPD patients at outpatient clinic visits, as shown in Table 9.
Most of the doctors (58.9%) did not perform spirometry to their patients, as shown in Table 10.
Depending on clinical diagnosis (55 doctors) and nonavailability (45 doctors) were the most common causes for not performing spirometry to patients, and 16 doctors were not doing so because of patients' finances, as shown in Table 11. There was a high statistically significant difference between doctors' place of work and performing spirometry to patients; most of the doctors in Abbassia Chest Hospital did not perform spirometry(78.33%), whereas in Ain Shams University Hospitals only 36.5% and in Ministry     Hospitals 100% did not perform spirometry, apart from Abbasia Chest Hospital, as shown in Table 12.
There is a highly significant correlation between doctors' years of practice and following GOLD guidelines in daily practice, being least in doctors who had more than 20 years of practice (GOLD 2010, 13% and GOLD 2013, 34.8%) and doctors who had less than 4 years of practice (GOLD 2010, 28.6% and GOLD 2013, 6.3%), as shown in Table 13.
Most of the doctors (90.7%) prescribed systemic steroids in COPD exacerbations, as shown in Table 14. Most of the doctors prescribed systemic steroids mostly for less than 14 days, less than 1 (46.2%) week, and from 10 to 14 (45.3%) days, in case of COPD exacerbations, as shown in Table 15.
All doctors were increasing the dose of bronchodilators, with one internist not giving treatment at all; only 48.4% of doctors ordered physiotherapy to COPD patients and 99.2% were prescribing mucolytics in exacerbations, as shown in Table 16.
All doctors prescribed antibiotics for COPD patients in exacerbation in this study, except one internist.
Most of the doctors prescribed antibiotics in moderate and severe exacerbations (59.4%), whereas the others (40.6%) prescribed antibiotics in mild, moderate, and severe exacerbations, as shown in Table 17.
Patient noncompliance and nonavailability (36.7% for each) were the two most common causes for not using noninvasive ventilation in COPD patients, as shown in Table 20. The results show a highly significant correlation between doctors' specialty and performing spirometry to patients, being lowest in internal medicine doctors (83.9%) followed by chest residents (65.8%), as shown in Table 21. The results show a highly significant correlation between doctors' specialty and following GOLD guidelines in daily prescription, which was highest in chest doctors with MD (GOLD 2013, 76.5%) and lowest in internal medicine doctors (12.9% for GOLD 2010 and 19.4% for GOLD 2013), as shown in Table 22.
Most doctors (89.8%) prescribed inhaled corticosteroids to COPD patients as recommended by guidelines for patients with frequent exacerbation and severe or very severe COPD patients, and 10.2% of doctors for severe or very severe COPD patients. One internist did not give inhaled corticosteroids and one MD gave inhaled corticosteroids according to physician experience, as shown in Table 23 and Fig. 1.

Discussion
COPD has emerged as the most important respiratory disease globally, and its prevalence and impact on the society is expected to increase until it becomes the third ranking cause of death by 2030 worldwide [6]. The GOLD report is one of the most frequently used documents for managing COPD patients worldwide [5]. Stratification of patients according to COPD severity is a crucial aspect in initiating treatment. Appropriate COPD management could reduce its impact on patients' quality of life and health service costs [5]. For the first time, the revised GOLD guidelines published in 2011 suggest a combined assessment of symptoms, the degree of airflow limitation as measured by spirometry, and the risk  Do not work in ICU 21 (22.5) of exacerbation, with patients grouped into four different classes. Many studies showed that the adherence to treatment guidelines is low, especially in the less developed countries [7][8][9][10]. Another recent study shows low rates of adherence to gold guidelines in COPD treatment [11]. Adherence to clinical guidelines shows considerable variability in outpatient clinics managing COPD patients [12].
Another study shows that adherence to GOLD guidelines is only partially met by general practitioners in their general practice and shows higher prescription appropriateness by pulmonologists [13].  [14]. The mean age of physicians who participated in this study was 33.94±9.561 years. This is nearly the same found in a study conducted to assess physicians' understanding, adherence, and barriers to implementation of GOLD guidelines in Nigeria where the mean age of participating physicians was 34±5 years. The physicians' sample was characterized by young age; most of the physicians were in the age group of 24-29 (43.4%) years and 30-40 (31.8%) years [15]. In contrast, a guideline-based survey of outpatient COPD management by pulmonary specialists in Germany revealed that physicians were mainly in the 41-50 (41%) age group and 51-60 (38%) age group [16]. The results showed that 69% of   COPD, chronic obstructive pulmonary disease.

Figure 1
Distribution of doctors according to daily prescription practice (others like: practical experience, guidelines rather than GOLD).
physicians who participated in the current study were male. This matched with a study that assessed physician and patient perceptions in COPD in USA, where only 34% of participated physicians were female [17]. The current study showed that 48.8% of physicians had less than 4 years of practical experience. However, in a study conducted among 590 pulmonary specialists in Germany, 35.4% of physicians had 11-20 years of practical experience, 20.8% had 5-10 years, and 25.8% had less than 5 years of practice [16]. In this study, about 52.7% of physicians examined 20-40 COPD patients per month in the outpatient clinic, 58.1% of physicians stated that 10-20 of COPD patients seen monthly in the out patient clinic (OPC) needed hospitalization, and 74.4% of doctors diagnosed less than 20 new COPD patients per month. However, one study found that 48% of chest specialists reported treating 101-200 COPD patients per month and 61% of physicians stated that less than 5% of their COPD patients had at least one exacerbation-related hospitalization per year [16], whereas in one study, a national survey among Belgian physicians, the pulmonologists saw on average 65 COPD patients per month and 109 new COPD patients per year [18].
In the present study, 43.4% of doctors followed GOLD guidelines in daily prescription practice (33 doctors followed new GOLD, whereas 23 followed old GOLD). These results matched with a study during a cross-sectional survey of internal and family medicine in Nigeria; 90 (57.7%) of the participating physicians were aware of the COPD guidelines [15]. However, in another study conducted in Germany, the most followed guidelines of COPD were the national guidelines (51%), and then GOLD guidelines (40%) [16]. In a study conducted in Italy to observe COPD patient management, 89.9% of general practitioners declared knowing national/international guidelines for COPD management [19]. However, a study found that the leading barriers to the nonadherence to the COPD guidelines were lack of familiarity (39.8%), lack of awareness (23.1%), and lack of time (19.2%), whereas 22 (14.1%) participants cited disagreement with the guidelines as a barrier to nonadherence [15].
In the present study, only 53 doctors perform spirometry to their COPD patients; the most cited reasons for not performing the test were depending on clinical diagnosis followed by nonavailability and low economic status of the patient. The same was found in a US study conducted to assess attitudes and barriers to COPD guideline usage by primary care physicians [20]. When COPD is suspected the diagnosis should be confirmed by spirometry. Despite that 69.2% of doctors agreed with the guidelines, only 23.6% ordered spirometry when patients reported symptoms that lead to expected COPD. Primary care physicians who participated in that study indicated that there were considerable external barriers to obtaining confirmatory spirometry use such as lack of a working spirometer onsite (46.8%), cost of spirometry testing to patient (33.0%), lack of spirometry testing nearby (18.4%), and patient reluctance to be tested with a spirometer (42.4%).
This matched with the current study where there was a statistically significant difference between doctors' place of work and performing spirometry to COPD patients; 47 chest physicians at Abbassia chest hospital did not perform spirometry to patients, which could be because of nonavailability.
In this study, there was a statistically significant difference between doctors' years of practice and performing spirometry to COPD patients; most doctors with less than 4 years of practical experience did not perform the test. This could be because most of those doctors (65.1%) do not follow GOLD guidelines in daily practice.
In the current study, all doctors stated that they do not have available structured rehabilitation programs for COPD patients in their hospitals, whereas only five chest physicians claimed offering a structured educational program to their COPD patients in the form of repeated instructions at the outpatient clinic visits. Moreover, only 24.8% of physicians (27 chest physicians and five internists) admitted their COPD patients to a smoke cessation program. Most of them admitted less than 50 COPD patients per year in such a program. This is nearly similar to a study conducted in Belgium to investigate to what extent COPD guidelines differed from the existing practice among physicians: only 44% of the pulmonologists had a structured rehabilitation program for their patients and only 34% of them had a structured smoking cessation program and they on the average only admitted three patients per week to it [18].
Inhaled steroids are appropriate in patients with severe or very severe COPD or in patients with frequent exacerbations not adequately controlled by long-acting bronchodilators [21]. In the present study, 92.2% of doctors claimed prescribing inhaled corticosteroids according to previous recommendations.
The combined assessment proposal [22] is expected to reflect the complexity of COPD better than the unidimensional (forced-exipiratory volume for 1 s) analysis previously used for staging the disease [23], and is therefore a potentially important step forward toward a more personalized approach to COPD [24]. However, in this study only 31 physicians prescribed medication according to new GOLD guidelines. Physicians followed new GOLD-prescribed short acting bronchodilators (SABDs) in all patient groups (A, B, C, and D). LABDs were prescribed mainly in patients who belonged to groups B, C, and D and long-acting β2 agonist with inhaled corticosteroid were prescribed only in C or D patient groups, whereas theophyllines and mucolytics were prescribed mainly in patients who belonged to groups C and D. The new GOLD guidelines includes a wider choice of respiratory medications and different other possible treatments that could be prescribed alone or in combination with firstchoice drugs, making prescription adherence to guidelines more possible to physicians. On the other hand, 93 physicians prescribed treatment according to COPD severity level. Short-acting β 2 agonist, theophylline, and mucolytics were the more frequently prescribed drugs, whereas LAMAs were the least frequently prescribed drugs and long-acting β 2 agonist and inhaled corticosteroid were prescribed mainly in moderate and severe or very severe disease stages. These results may reflect that doctors' prescription could be affected by the economic status of the COPD patient.
In case of treating COPD exacerbations, the results showed that 90.7% of doctors prescribed systemic steroids for COPD patients with exacerbation. About 46.2% of doctors prescribed it for less than 1 week duration, whereas 44.3% of them prescribed it from 10 to 14 days. All doctors increased doses of bronchodilators, whereas only 48.4% of them ordered physiotherapy to their patients. In this study, all doctors prescribed antibiotics for COPD patients with exacerbation, 59.4% of physicians prescribed antibiotics in moderate and severe exacerbation, whereas 40.6% prescribed them in mild, moderate, and severe exacerbations. However, a study conducted among Belgium physicians to assess COPD patient management according to GOLD guidelines revealed that the first treatment for an exacerbation was increased doses of bronchodilator (75%), followed by systemic steroids (69%), physiotherapy (40%), and antibiotics (35%) [18].
The results showed that the most common antibiotics prescribed by physicians to COPD patients in exacerbations were macrolides (66.6%), third-generation cephalosporins (53.5%), respiratory quinolones (38%), extended penicillins (28%), or according to culture (25.9%), whereas a study conducted at Ain Shams University Hospitals to evaluate prescription practices of antibiotics in respiratory tract infections showed that broad-spectrum penicillins were the most frequently prescribed antibiotics for COPD and acute exacerbation (AE) (39%), followed by cephalosporins (24%) and macrolides (23%), whereas the least frequently prescribed antibiotics were quinolones (14%) [14].
Several studies have shown that noninvasive positivepressure ventilation improves respiratory acidosis, improves respiratory rate, decreases need to invasive mechanical ventilation, and increases survival time [25][26][27]. In cases of COPD patients who suffer from acute hypercapnic respiratory failure but without hypotension or reduced level of consciousness, noninvasive ventilation was used only by about 35.7% of physicians. The results showed that this could be mainly because of patient noncompliance followed by nonavailability.
In the current study, there was a statistically significant difference between doctors' specialty and following guidelines in daily prescription. Most of the chest residents and internal medicine doctors did not follow GOLD recommendations in daily prescription. In a similar study conducted in Nigeria, 57.7% of doctors were aware of the COPD guidelines; these comprised all the pulmonologists and internists, 54 (65.1%) internal medicine residents, two (50%) family physicians, 22 (46.6%) medical officers, and six (37.5%) family medicine residents [15].
In this study, the results showed correlation between doctors' specialty and performing spirometry to COPD patients: 82.4% of chest physicians with MD and 48.8% of chest physicians with masters degree performed spirometry to patients because most of them followed GOLD guidelines in daily practice.

Recommendations
Educational interventions are required to achieve optimal care for COPD patients according to GOLD guidelines. The appropriate use of COPD medications is both cost-effective and clinically beneficial for patients. In addition, evidence-based comparative studies should be carried out in our country between recommended first-choice drugs, alternative choice drugs, and other possible treatments mentioned in new GOLD pharmacologic management recommendations. Spirometry should be widely available in hospitals and public health system with trained medical staff. Doctors should order spirometry to COPD patients every 6 months to follow up airway obstruction level. Changes in healthcare systems must include more effective ways to transfer knowledge into clinical practice. In teaching hospitals and specialized chest hospitals, there should be an integrated medical team that consists of well-trained nurses, well-trained chest physicians, psychiatrists, nutrition specialists, and physiotherapists to achieve optimal management of COPD patients. The different means of media should increase the awareness of the community to COPD and its relation to smoking habit and air pollution. However, as real life often demands an individualized treatment approach, the contribution of other factors to COPD treatment (comorbidities, access to healthcare facilities, patient educational level) also needs to be investigated in the future. Despite a broad international consensus on the basic principles for treating COPD, different national healthcare systems, economies, and medical tradition may influence the actual medical practice and drug prescription attitudes. Therefore, some deviations from the gold standard are to be expected.