Level of Adherence to GOLD Guidelines for Management of Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease: Is There a Difference Between Patient Management in Different Hospital Wards?

Abstract
Background: The purpose of this study was to evaluate the implementation of GOLD guideline in patients with an acute exacerbation of Chronic Obstructive Pulmonary Disease (COPD). 
Methods: In a cross-sectional study, all patients with COPD exacerbation referred to Shariati hospital from January 2014 to March 2015 were investigated. The level of adherence to GOLD guideline in three areas of hospital admission, therapeutic components of inpatient management (pharmacologic treatments, respiratory support) and discharge plan was assessed via reviewing patients’ medical profile. Each subject was classified as complete, non-complete and not evaluated in terms of adherence to the guideline.
Results: In this study, 125 patients with mean age of 67.64±1.71 years including 100 (80%) males were studied. Also, 104 and 21 patients were hospitalized in pulmonology and general medicine wards, respectively. In the present study, the adherence to GOLD recommendations for hospital admission, pharmacologic treatment and non-pharmacologic management were 92, 97.6 and 44.2%, respectively. Despite the high level of adherence to pharmacologic management, total adherence to non-pharmacologic interventions was poor.
Conclusion: Although high level of adherence to pharmacological management of COPD was observed, there was overtreatment particularly in case of antibiotics prescription. In addition, non-pharmacological management was not considered in over half of the patients. 
Keywords: Anti-bacterial agents, Chronic obstructive pulmonary disease, Hospitalization, Humans

Introduction
The main characteristic of Chronic Obstructive Pulmonary Disease (COPD) is irreversible obstruction of airways (1). Not only is COPD a direct cause of death in 7.8% of the whole deaths of the globe, but it is also considered the third major cause of death in smokers with malignancy and cardiovascular diseases (2). At the present time, COPD exacerbation is considered an acute deterioration in respiratory indications which engender changes in patients’ daily medications (3). One of the pivotal incidents during disease progression is COPD exacerbation which causes adverse impact on patients’ quality of life, aggravation of the symptoms and patient’s performance decreased lung function, increased risk of readmission, mortality, and socioeconomic costs (4). Therefore, appropriate treatment has tremendous effect on clinical course, quality of life and burden of the disease (5). Global initiative for COPD (GOLD) was first introduced in 2001, in order to provide evidence-based standards for improving diagnosis, treatment and prevention of COPD (6,7). Previous studies indicated that adherence to GOLD guidelines would improve quality of care, reduce proceeding exacerbation of risk and subsequently result in reduced mortality (6-8). The poor adherence to guideline recommendations has been reported in several studies (9). In a study by Masoompour et al in Iran, the overall adherence to GOLD guideline was reported 67.2% (10). They focused on pharmacologic management (10) but other issues in a typical episode of COPD exacerbation like use of non- invasive ventilation, advice to smoking cessation and vaccination or pulmonary rehabilitation, had not been considered. In this study, the level of adherence to GOLD guideline, particularly adherence to GOLD guidelines in general medicine and pulmonology wards of Shariati Hospital, was thoroughly investigated.

Materials and Methods 
This cross-sectional study was carried out in a 14 -month period during 2014-15 in Shariati Hospital, Tehran, Iran. The study was approved by ethics committee of Tehran University of Medical Sciences and ethical principles of Declaration of Helsinki were observed. The participants of this study were 125 patients with previous COPD diagnosis admitted during an acute deterioration of respiratory symptoms. In our study, the diagnosis of aggravation was exclusively based on clinical presentation such as an acute change in dyspnea severity, increase in sputum production and cough which led to additional admission. It is worth mentioning that patients who concurrently had asthma or other chronic lung diseases and decompensated heart failure were excluded.
The data was extracted from patients’ medical records during their admission including medical history, prescribed medications, lab tests, imaging, residents’ and attending notes. For determining the level of adherence to GOLD guideline, patients’ medical records were reviewed during admission. Then, the findings were compared with GOLD recommendations. Our focus was on 2014 GOLD recommendations for hospital admission, therapeutic components of inpatient management (pharmacologic treatments, respiratory support) and discharge plan as listed in tables 1 and 2. The level of adherence for each case has been rated as complete, non-complete and not evaluated. In the case of adherence to guideline, the patients were categorized in 3 distinct groups in each field. In complete adherent group, all recommendations were followed. In non-complete adherent group, the recommendations were partially conducted and in not evaluated group, the data in their records were insufficient. Also, any difference in COPD management between pulmonologist and internist was assessed. Throughout the study period, the 2014 GOLD guideline for evaluation was utilized.

Statistical analysis 
All data were expressed as mean± SD for continuous variables and frequency percentage for categorical variables. Data was analyzed using SPSS software version 22.

Results
In a cross-sectional study, 125 patients with diagnosis of COPD exacerbation were admitted to the Shariati Hospital. The participants’ mean age was 67.64±11.71
years. The admission rate (ratio) at pulmonology and general medicine wards was 104(83.2%) and 21 (16.8%) patients, respectively.
The demographic and clinical characteristics of the participants are summarized in table 2. According to the guideline, hospital admission was indicated for 115 (92%) patients. Chest X-ray (CXR) and Arterial Blood Gas (ABG) were done for all patients.
Overall, 62 (49.6%) cases had previous spirometry and the mean±SD of FEV1/FVC, FEV1 and FVC of the patients were 64.09±15.74, 47.75±28.34 and 56.98±21.91, respectively. On admission, based on ABG, 52 (41.6%) cases had respiratory acidosis, 94 (75.2%) had hypoxemia and 87 (69.6%) had hypercapnia. Table 3 shows the level of adherence to GOLD recommendations in our study population. 
All patients received short acting beta agonists and anticholinergics in accordance with GOLD guideline. Corticosteroid and prednisolone 30-50 mg per day or equivalent had been prescribed in 120 cases for 10-14 days. Antibiotics were prescribed for nearly all patients while according to 2014 GOLD guideline (Table 1), antibiotics should be given only for 102 (81%) of our cases. In our study, xanthine derivative (Aminophylline, theophylline) had not been started for any patient. There was no statistically significant difference between pulmonary and general medicine ward in pharmacologic treatment. 
All patients received respiratory support. Non-Invasive Ventilation (NIV) was used for 40 (32%) pa