Running head: IMPROVING COPD SCREENING

Improving COPD Screening in an Internal Medicine Practice by Implementing the GOLD
Guidelines
Jillian Manng, BSN, RN-BC
Diane Nunez, DNP, RN, ANP-BC, FNAP
Arizona State University

Corresponding Author:
Jillian Manng, BSN, RN-BC
2617 E. Charlotte Dr.
Phoenix, AZ 85024
jillianmanng@gmail.com
602-367-7847

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Improving COPD Screening in an Internal Medicine Practice by Implementing the GOLD
Guidelines

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Abstract

Purpose: Improve chronic obstructive pulmonary disease (COPD) screening in primary care by
implementing Global Initiative for Chronic Obstructive Lung Disease (GOLD) screening
criteria.

Background and Significance: Evidence shows primary care providers (PCPs) are not adhering
to the GOLD Guidelines for COPD screening.

Methods: Guideline education with pre/post-intervention survey and percent of eligible
participants screened.

Results: Pre-intervention surveys (n=10) and post-intervention surveys (n=8) completed.
Significant increase in knowledge regarding the CAT score (M score = 11.50, U = 24.000,
p<.05). Part 2) 24% (n=6) of participants were screened with the CAT questionnaire.

Conclusions: PCPs are aware of the GOLD Guidelines, but do not always adhere to its
recommendations. Future research should concentrate on effective ways to implement the GOLD
Guidelines screening recommendations in primary care clinics.

Keywords: chronic obstructive pulmonary disease, COPD, GOLD guidelines, COPD
screening

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Introduction

Chronic obstructive pulmonary disease (COPD) is a progressive respiratory disease that
affects people worldwide. Although there are clinical guidelines for the diagnosis and
management of COPD, many primary care providers (PCPs) are not adhering to guideline
recommendations. Improved adherence to guidelines can decrease exacerbations and improve
health and quality of life (QOL) for those with COPD.
Background and significance
COPD is a global health concern. The worldwide prevalence of COPD in people over 40
years is estimated between 9% and 10% (Landis et al., 2014). The disease is projected to become
the third leading cause of mortality worldwide by 2020 (Perez, Wisnivesky, Lurslurchachai,
Kleinman, & Kronish, 2012). In the United States, COPD is the third-ranked cause of death:
120,000 deaths each year (Angelis et al., 2013). Over 12 million Americans are diagnosed with
COPD, although 24 million have impaired lung function and may be undiagnosed (Guarascio et
al., 2013).
The Global Initiative for Obstructive Lung Disease (GOLD) guidelines focus on the
screening and treatment of COPD to relieve and reduce symptoms while preventing future
adverse health effects such as acute exacerbations (GOLD, 2016). They are considered a
standard of care (Perez et al., 2012). PCPs are familiar with the GOLD guidelines, but
demonstrate suboptimal adherence (Perez et al., 2012).
COPD Diagnosis and Mismanagement
COPD is often misdiagnosed or underdiagnosed (Guarascio et al., 2013; Joo, Au,
Fitzgibbon, McKell, & Lee, 2011; Salinas et al., 2011; Melbye, Drivenes, Dalback, Leinan,
Høegh-Henrichsen, & Østrem, 2011). This is significant due to evidence that the most rapid

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decline in lung function occurs early in the disease (Csikesz & Gartman, 2013). As part of the
guidelines screening process, spirometry should be used to help determine the severity of COPD
(GOLD, 2016). However, studies demonstrate that spirometry is underutilized (Joo et al, 2011;
Salinas et al., 2011).
Significance of the Problem
Anxiety, QOL, and depression have been correlated with COPD. As disease progresses
from moderate to severe, there is often a decline in QOL attributed to financial burden caused by
hospitalizations, loss of work productivity, and disability (Borge, Mengshoel, Moum, & Wahl,
2016; Rycroft et al., 2012).
PICOT Question and Search Strategy
Because evidence demonstrates that PCPs are not appropriately screening for COPD, the
following clinically relevant PICOT question was asked, “In primary care healthcare providers,
how does application of the GOLD guidelines compared to usual care affect emergency
department visits and hospital admission rates?”
An exhaustive search was performed to find literature related to the PICOT question. The
medical-based databases included were: EBSCOhost, PubMed, Cochrane Review, Proquest
Medline, and Elsevier ScienceDirect. Keywords were carefully selected and the initial searches
most commonly included: COPD, chronic obstructive pulmonary disease, GOLD, GOLD
guidelines, primary care, internal medicine, and family practice. To further narrow results, the
additional keywords management, adherence, (re)admission, diagnosis, improvement, and
spirometry combined with Boolean connectors AND/OR produced a broad yet manageable list
of articles to review and analyze.

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The final yield for all three databases was 159 citations. Of these, 22 articles were
selected for closer review. Twelve articles were then excluded based on incomplete data, use of
guidelines other than the GOLD guidelines, and inclusion of settings other than primary care.
Evidence Synthesis
Five studies focused on physician adherence to the GOLD guidelines, three studies
examined COPD screening, and two studies analyzed COPD-related hospital or emergency
department readmissions. The majority of studies were conducted in the U.S. Sample sizes
ranged from 132 to 23,957 and included patients or providers depending on the objectives of the
study. The articles ranged from level I to level IV evidence, with eight of the ten studies ranking
as level IV. Although level IV articles are only considered moderately strong evidence, they
reveal important trends in GOLD guideline adherence.
The overarching outcome is that PCPs do not properly follow the GOLD guideline
recommendations for COPD screening and treatment. Patients are readmitted to hospitals and
emergency departments due to lack of knowledge regarding disease management and improper
use of healthcare resources for disease exacerbation. The evidence suggests that PCPs are using
subjective information to diagnose and treat patients with COPD, which leads to inaccurate
diagnoses and management.
The Project
A project was designed to create an objective, standardized COPD screening process for
an internal medicine practice. The benefits of the project include earlier and more accurate
diagnoses of COPD, and therefore, earlier treatment and slowed disease progression. The
Chronic Care Model (CCM) was used as a framework to understand COPD management and
guide the project design. The Stetler Model of Research Utilization serves as an effective model

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for individual practitioners to incorporate critical thinking and research findings into practice
(Melnyk & Fineout-Overhalt, 2015). The Stetler Model was deemed appropriate because the
providers at the internal medicine site practice independently.
Methods
The Institutional Review Board at Arizona State University granted approval for an
expedited review in August 2016. The intervention was twofold. First, providers were given a
pre-intervention survey with three knowledge questions about the GOLD Guidelines and nine
questions about their current practice regarding COPD screening and diagnosis. An identical
post-intervention survey was administered four months later at the project’s completion.
The second part of the intervention was implementation of the GOLD Guideline
screening measures using the COPD Assessment Test (CAT) and spirometry. The setting was a
large internal medicine practice in the greater Phoenix area. The electronic medical record
identified potential participants who met the inclusion criteria: age 40 years or older, current or
former smoker, and a pre-scheduled annual exam between August and December 2016, which
would facilitate discussion of screening results.
A graduate student, who was a co-investigator in the project, called participants for
screening using the CAT. Because this was not resulting in a high level of participation, the
delivery method was changed to use the patient portal system to administer the questionnaire. A
score of 10 or higher on the CAT resulted in subsequent screening with spirometry. The CAT
results and/or spirometry results were then forwarded to his/her PCP to be discussed at the
annual exam.

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Results

Sixty-two percent (n=10) of providers completed the pre-intervention survey and 50%
(n=8) completed the post-intervention survey. Knowledge scores regarding the CAT score
significantly increased based on the Mann Whitney U test (M score = 7.90) (M score = 11.50, U
= 24.000, p<.05) and had a moderate positive correlation based on the Spearman test (rho (16) =
.478, p<.05).
Twenty-four percent (n=6) of the 25 participants called at home responded to the CAT.
Only one participant scored over 10 and completed spirometry. Over 150 patient portal messages
were delivered; however, no responses were received.
Discussion
The results demonstrate similar trends found in the current literature; PCPs have
suboptimal adherence to the GOLD Guideline recommendations for COPD screening. Although
PCPs report knowing about the guidelines, they also recognize that they do not consistently
follow its recommendations for COPD screening using the CAT and spirometry.
Strengths
The project site had a large pool of potential participants that met the inclusion criteria.
The site also had all of the necessary equipment to perform the screenings, including the
nebulizer and spirometer to perform pre and post-bronchodilation spirometry. Therefore, the
project’s cost was minimal. Additionally, the CEO and clinical director at the site were
supportive, as well as a nurse practitioner who assisted with project implementation and survey
administration and collection.
Weaknesses

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The project had several weaknesses. First, the graduate student/co-PI of the project was
responsible for all of the screening phone calls and patient portal messages, and it was difficult to
coordinate schedules with the business hours of the project site. Additionally, the survey
distribution methods were not ideal. Many potential participants did not answer the phone when
they were called. To circumvent the issues associated with phone call screening, the patient
portal system was used to deliver the CAT. Unfortunately, the survey format in the patient portal
system was not user friendly to respond to the messages. Future medical practices should utilize
this method only if the questionnaire could be easily formatted into their messaging system.
Recommendations
Future research should focus on streamlining a process for CAT questionnaire
distribution in a primary care setting. Suggestions for this are to include the CAT during the
annual exam for patients at risk for COPD, which would encourage participation by minimizing
the office visits required to complete screening. Additional research could evaluate alternate
methods of CAT delivery to make it user-friendly for a wide population of people. Telephone
screenings are not the most time effective and patient portal messages require a user-friendly
interface to encourage responses.
Conclusion
The project’s purpose was to implement the GOLD Guideline screening
recommendations into an internal medicine practice that lacked a standardized process for COPD
screening. Although the small number of patient participants was a weakness, the project brought
awareness to the providers about the GOLD Guidelines and COPD screening. By better
managing COPD, patients will have an improved QOL and providers will decrease the use of
resources and costs associated with COPD exacerbations.

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