Treatment of patients with chronic obstructive

O R I G I N A L
A R T I C L E pulmonary disease as practised in a defined
Hong Kong community: a cross-sectional pilot survey
WC Yu 余衛祖
Emily LB Tai 戴麗文 Objectives To examine the characteristics of chronic obstructive pulmonary
SN Fu 傅秀雅 disease patients of the Kwai-Tsing area, Hong Kong, and the
KC Kwong 鄺國柱 chronic treatments they received.
YC Yeung 楊耀昌 Design Cross-sectional survey.
Y Chang 張 銳 Setting Four clinic settings in Hong Kong: Respiratory Specialist Clinic,
YK Yiu 姚玉筠 Princess Margaret Hospital (group 1); Medical Specialist Clinics,
CM Tam 譚卓明 Princess Margaret Hospital (group 2); General Outpatient
Clinics, Princess Margaret Hospital (group 3); South Kwai Chung
Chest Clinic, Department of Health (group 4).
Patients Thirty physician-diagnosed chronic obstructive pulmonary
disease patients in each of the above groups with post-
bronchodilator 1-second forced expiratory volume/forced
vital capacity ratios of less than 70% predicted values, who had
been followed up at any of the participating clinics for at least 6
months.
Results There were 111 male and nine female patients. The median age
was 72.5 years and 79% had at least one medical co-morbidity.
The mean duration of their chronic obstructive pulmonary
disease was 9.8 years, and their mean post-bronchodilator 1-
second forced expiratory volumes were 45% (for males) and
58% (for females) of predicted values. There were significantly
fewer stage I and more stage IV patients in group 1. Influenza
vaccination coverage within the previous 1 year was 54% and
did not differ significantly between groups. Chronic obstructive
pulmonary disease education was given significantly more
often to group 1 patients. Short-acting beta agonists were
used to treat all patients but long-acting bronchodilators and
pulmonary rehabilitation were used almost exclusively in
group 1. Overall, long-acting bronchodilators and pulmonary
rehabilitation were offered to 16% and 5%, respectively,
Key words of those for whom these were indicated (according to
Airway obstruction; Forced expiratory
international guidelines).
volume; Lung diseases, obstructive;
Pulmonary disease, chronic obstructive; Conclusion In general there was insufficient education and under-treatment
Vital capacity for chronic obstructive pulmonary disease patients. Management
Hong Kong Med J 2011;17:306-14
of such patients warrants improvements by way of increased
accessibility to structured education programmes, pulmonary
rehabilitation programmes, long-acting bronchodilator drugs,
Department of Medicine and Geriatrics,
Princess Margaret Hospital, Hong Kong
and respiratory specialist care.
WC Yu, MB, BS, FHKAM (Medicine)
KC Kwong, MB, BS, FHKAM (Medicine)
YC Yeung, MB, BS, FHKAM (Medicine) New knowledge added by this study
Y Chang, MB, BS, FHKAM (Medicine) • Chronic obstructive pulmonary disease (COPD) patients are old, and mostly males with
TB & Chest Service, Department of medical co-morbidities.
Health, Government of HKSAR, Hong
Kong
• There is significant under-use of long-acting bronchodilators and pulmonary rehabilitation in
ELB Tai, FHKCP, FHKAM (Medicine) managing these patients.
CM Tam, MB, BS, FHKAM (Medicine) • A significant proportion of severe to very severe COPD patients are followed up in primary
Family Medicine Service, Kowloon West care clinics.
Cluster, Hospital Authority, Hong Kong
Implications for clinical practice or policy
SN Fu, MFM (CUHK), FHKAM (Family Medicine)
YK Yiu, MB, BS, FHKAM (Family Medicine) • Proper assessment of COPD disease severity enables appropriate treatment.
• Patients with severe to very severe COPD may be better managed at specialist respiratory
Correspondence to: Dr WC Yu clinics.
Email: yuwc@[Link]

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 # Treatment for chronic obstructive pulmonary disease #

Introduction
Chronic obstructive pulmonary disease (COPD) 香港其中一個區域的醫院診所對慢性阻塞性肺病
imposes a high burden. According to World Health 患者的治療：橫斷面試點調查
Organization estimates, 80 million persons worldwide
have moderate-to-severe COPD, and in 2005 more 目的 探討香港葵青區慢性阻塞性肺病患者的特性以及接受
than 3 million people died of the disease, which 的長期治療。
corresponds to 5% of all global deaths.1 In 2002, 設計 橫斷面調查。
COPD was the fifth leading cause of death, and since 安排 香港葵青區轄下四間診所：瑪嘉烈醫院胸肺科專科
mortality from it continues to increase, the disease is 診所（第一組）；瑪嘉烈醫院內科專科診所（第二
likely to become the third leading cause of death by 組）；瑪嘉烈醫院普通科診所（第三組）；衛生署轄
2030.1 In Hong Kong the burden of COPD is also high2-4; 下的南葵涌胸肺科診所（第四組）。
affected patients currently occupy approximately 10%
of all medical beds in public hospitals, and as a cause 患者 每個組別於上述診所隨訪期至少有六個月而被醫生確
of death this disease is ranked fifth. 診的30位慢性阻塞性肺病患者，他們使用支氣管擴張
劑後用力呼氣一秒容積／用力呼氣肺活量比例均少於
The clinical management of COPD is complex. 預測值的70﹪。
According to the Global Initiative for Chronic
結果 共有111位男性及9位女性患有慢性阻塞性肺病，他們
Obstructive Lung Disease (GOLD) guidelines,
的年齡中位數為72.5歲，平均患病年期為9.8年；其
COPD management has four components,
中79%至少有一種共病。患者使用支氣管擴張劑後用
namely: assessment and monitoring, reducing risk
力呼氣一秒平均容積為預測值的45%（男性）及58%
factors, managing stable disease, and managing
（女性）。第一組中明顯有較少I期及較多IV期患者。
exacerbations. Managing stable disease is further
過去一年內流感疫苗接種覆蓋率為54%，不同組別間
divided into education, pharmacological treatment,
未見顯著相關性。第一組患者明顯有較多機會接受慢
and non-pharmacological treatment.5 However, the
性阻塞性肺病的健康教育。所有病人都曾接受短效β
level of adherence to guidelines has been consistently
受體激動劑的治療，但幾乎只有第一組的患者有長效
unsatisfactory, as revealed by overseas questionnaire
支氣管擴張劑及肺康復治療。（按國際準則）長效支
surveys targeting respiratory physicians and primary
氣管擴張劑及肺康復治療分別給予16%及5%的患者。
care physicians.6-11 Specifically, under-utilisation of
effective treatments and under-use of spirometry is of 結論 總括來說，慢性阻塞性肺病患者的健康教育和治療並
particular concern. Moreover, physician knowledge 不足夠。要改善慢性阻塞性肺病患者的治療結果，必
of COPD treatment guidelines is generally poor.12-15 須為病人提供有系統的教育服務，並確保他們有更多
機會接受肺康復治療計劃，以及長效支氣管擴張劑和
Active identification of problem areas could
呼吸專科護理。
be useful in designing treatment programmes aimed
at improving COPD care. One approach to observe
the level of adherence to clinical guidelines is to
examine COPD subjects prospectively to assess their Thirty COPD subjects were recruited from each
disease severity and then correlate the same with of the following settings:
treatments they actually receive. To our knowledge,
• Group 1: Respiratory Specialist Out-Patient Clinic,
such a study has not been performed locally. We
Department of Medicine & Geriatrics, PMH;
therefore set out to conduct a prospective survey
on COPD patients managed in different health care • Group 2: General Medical Specialist Out-patient
settings in a local community (Kwai Chung and Tsing Clinics, Department of Medicine & Geriatrics,
Yi, or Kwai-Tsing) with a population of about 530 000 PMH;
inhabitants. The primary objective was to observe • Group 3: All five HA Family Medicine Clinics or
the management practice for COPD in different General Out-Patient Clinics in the Kwai-Tsing
health care settings. The secondary objective was to area, where there was no set quota for each and
correlate disease severity with the level of treatments subjects were drawn randomly; and
received.
• Group 4: South Kwai Chung Chest Clinic,
Department of Health.
Methods During planning of this study, we intended
This was a multicentre cross-sectional survey carried to recruit a fifth group of 30 patients with regular
out in the Department of Medicine and Geriatrics, follow-up by general practitioners. We found very
Princess Margaret Hospital (PMH), Hong Kong. few patients in this category however, and hence this
Collaborating sites included general out-patient group was not included.
clinics in the Kwai-Tsing area run by the Hospital Subject lists for groups 1 to 3 were generated
Authority (HA), and the South Kwai Chung Chest from the HA Clinical Data Analysis and Reporting
Clinic run by Department of Health. System (CDARS). The subjects had to have a valid

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 # Yu et al #

future appointment in that clinic and one of the When the subjects satisfied all inclusion and
following diagnostic codes: 490 (bronchitis, not exclusion criteria, written informed consent was
obtained. Demographic and illness data were then
specified as acute or chronic); 491 (chronic bronchitis);
492 (emphysema); 496 (chronic airway obstruction, collected using a standard data entry form. All available
not elsewhere classified). Subjects were randomly medical records were reviewed to obtain information
on the use of spirometry and chest radiographs
selected from the list and invited to participate in the
study by telephone. An appointment was given to in the diagnosis and subsequent management of
verbally consenting subjects to attend an interview COPD, vaccination, and current medication usage. If
at PMH. Recruitment for each group ceased when 30 not performed within the preceding year, spirometry
consenting and evaluable subjects had been accrued. was undertaken at PMH (as per American Thoracic
For group 4, since no patient list could be generated, Society/European Respiratory Society protocols16).
COPD subjects were invited to participate in the Moreover, it was a requirement that the subject
study as they attended the follow-up at the clinic. had no COPD exacerbation within the preceding 4
Otherwise the workflow was similar to the other weeks. Local reference values were used for FEV1 and
groups. other spirometric parameters.17 The 6-minute walking
distance test was performed, and pulse oximetry
At the PMH visit, which was the only study
monitoring being carried out before, during, and
visit, subjects were checked for study entry criteria.
after the test.
Inclusion criteria were: (1) physician-diagnosed
COPD; (2) post-bronchodilator forced expiratory After the study visit, the subjects continued
volume in one second (FEV1)/force vital capacity to attend regular follow-up at their original clinic.
ratio <70% of predicted; (3) regular follow-up at the A summary of the subject’s clinical findings and/or
participating clinic for treatment of stable COPD treatment recommendations was supplied to the
for at least 6 months; (4) willingness and ability caregiver on request.
to comply with study requirements (spirometry To compare mean values of patient variables in
and 6-minute walk test); and (5) willingness to give different groups, either analysis of variance (ANOVA)
written informed consent. Exclusion criteria were: (for samples generated from population following
(1) non-COPD diagnosis as judged by the principal normal distribution) or non-parametric Kruskal-
investigator; (2) regular follow-up at another clinic Wallis H (for all other situations) test were employed.
and/or irregular attendance at a participating clinic for To decide between these two methods, we used the
acute exacerbations of COPD or other problems; (3) Shapiro-Wilk test to check for normal distributions.
significant co-existing chronic lung disease (asthma, To compare distributions among groups, Pearson
pulmonary fibrosis, bronchiectasis, and restrictive Chi squared or Fisher’s exact tests (for analyses with
lung disease); and (4) history of lung resection. number of expected cases in certain categories less

TABLE 1. Subject screening and recruitment summary*

Group Clinic Screening and invitation Attended study visit Analysed

No. No. failed Reason No. No. excluded Reason
1 Respiratory PMH 37 4 Refused 30 0 30
1 Suspected active TB
1 Significant
bronchiectasis
1 Died before visit
2 Medicine PMH 35 3 Refused 32 2 Not COPD 30
3 GOPC total 37 3 34 4 30
Tsing Yi 9 2 Refused 7 2 Not COPD 5
Cheung Hong 7 0 7 0 7
South Kwai 9 1 Refused 8 0 8
Chung
North Kwai Chung 5 0 5 1 Not COPD 4
Ha Kwai Chung 7 0 7 1 Spirometry failed 6
4 Chest Clinic 35 4 Refused 31 1 Not COPD 30
All groups 144 17 127 7 120

* PMH denotes Princess Margaret Hospital, TB tuberculosis, COPD chronic obstructive pulmonary disease, and GOPC general out-patient clinics

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 # Treatment for chronic obstructive pulmonary disease #

TABLE 2. Demographics data

Demographics* Group 1 (n=30) Group 2 (n=30) Group 3 (n=30) Group 4 (n=30) Overall (n=120) P value†
M:F 28:2 26:4 30:0 27:3 111:9 0.242‡
Male % 93% 87% 100% 90% 93%
Age (years)
Mean 71.3 74.2§ 67.6§¶ 73.9¶ 71.8 0.004
Median 73 75 67 73.5 72.5
Range 60-81 57-86 46-87 62-86 46-87
Abode
Own home 29 (97%) 27 (90%) 30 (100%) 29 (97%) 115 (96%) 0.468‡
RCHE 1 (3%) 2 (7%) 0 (0%) 1 (3%) 4 (3%)
Others 0 (0%) 1 (3%) 0 (0%) 0 (0%) 1 (1%)
Chinese ethnicity 30 (100%) 30 (100%) 30 (100%) 30 (100%) 120 (100%) NA
Occupation
Labourer 26 (87%) 22 (73%) 29 (97%) 24 (80%) 101 (84%) 0.105‡
Retired 29 (97%) 28 (93%) 24 (80%) 28 (93%) 109 (91%) 0.208‡
Smoking habit
Never 2 (7%) 1 (3%) 0 (0%) 2 (7%) 5 (4%) 0.585‡
Previous 22 (73%) 20 (67%) 23 (77%) 24 (80%) 89 (74%)
Current 6 (20%) 9 (30%) 7 (23%) 4 (13%) 26 (22%)
Mean pack-year 74.4 65.5 55.7 50.9 61.5 0.128
Co-morbidity
Hypertension 10 (33%) 20 (67%)§ 7 (23%)§¶ 17 (57%)¶ 54 (45%) 0.002
BPH 7 (23%) 4 (13%) 4 (13%) 8 (27%) 23 (19%) 0.310
Old TB 3 (10%) 3 (10%) 6 (20%) 6 (20%) 18 (15%) 0.551‡
DM 2 (7%) 6 (20%) 3 (10%) 4 (13%) 15 (13%) 0.523‡
Any 24 (80%) 29 (97%)§ 17 (57%)§ 25 (83%) 95 (79%) 0.001
None 6 (20%) 1 (3%) 13 (43%) 5 (17%) 25 (21%)
* RCHE denotes residential care home for the elderly, BPH benign prostatic hypertrophy, TB tuberculosis, and DM diabetes mellitus
†
All P values are generated either from analysis of variance or Chi squared test, except otherwise indicated
‡
P value from Fisher’s exact test
§/¶
Pairwise significant difference from Tukey test (§), or Mann-Whitney U test with Bonferroni correction (¶)

than 5) were adopted. To deal with groups with or refused to participate in the study. Of the 127
discrepancies after identifying significant results, remaining subjects who attended the study visit, six
we used the post-hoc Tukey test for the ANOVA, were excluded because they did not have COPD, and
Mann-Whitney U test, Chi squared test for Kruskal- one because of failed spirometry. Breakdown for
Wallis H, and the Chi squared test. The alpha level the different clinics is shown in Table 1. Data of the
of Mann-Whitney U test and Chi squared test for remaining 120 subjects were analysed.
post hoc purposes was adjusted using the Bonferroni Overall there were 111 males and 9 females,
correction. A P value of less than 0.05 was considered all of Chinese ethnicity. Their median age was 72.5
statistically significant. years and the range was 46 to 87 years. The number
The study was approved by the Clinical who never smoked, ex-smokers, and current smokers
Research Ethics Committee of the Kowloon West were 5 (4%), 89 (74%) and 26 (22%), respectively. For
HA Cluster, as well as the Ethics Committee of the ever-smokers, the median pack-years was 71 with a
Department of Health. range of 5 to 200. Most subjects (115; 96%) lived in
their own homes; only four lived in residential care
homes for the elderly and one was a long-term in-
Results patient of a psychiatric institute. The majority of
Subject recruitment started in June 2008 and was subjects were labourers (101; 84%) and had retired
completed in June 2009. Seventeen of 144 randomly (109; 91%). The commonest medical co-morbidity
selected subjects either failed the initial screening was hypertension (54; 45%), followed by benign

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 # Yu et al #

TABLE 3. Chronic obstructive pulmonary disease severity*

Disease severity Group 1 (n=30) Group 2 (n=30) Group 3 (n=30) Group 4 (n=30) Overall (n=120) P value†
Duration of COPD (years)
Mean 8.6 10.4 11.3 8.9 9.8 0.465‡
Range 2-30 0.5-40 0.5-30 1-30 0.5-40
Post-BD FEV1 mean values (L)
Males 0.75§/¶/II 1.12§ 1.15¶ 1.10II 1.03 0.002‡
Males % predicted 34%§/¶/II 50%§ 48%¶ 50%II 45% 0.003‡
Females - - - - 0.84 NA
Females % predicted - - - - 58% NA
GOLD stage

} } }
Stage I 0 (0%) 5 (17%) 2 (7%) 3 (10%) 10 (8%)
Stage II 4 (13%)§/¶ 11 (37%)§ 12 (40%) 11 (37%)¶ 38 (32%) 0.021
Stage III 13 (43%) 9 (30%) 11 (37%) 13 (43%) 46 (38%)
Stage IV 13 (43%) 5 (17%) 5 (17%) 3 (10%) 26 (22%)
Mean BMI (kg/m2)
Males 21.4 22.6 21.5 22.9 22.1 0.295
Females - - - - 24.0 NA
Mean 6-minute walking distance (m)
Males 262 242 267 238 253 0.421
Females - - - - 264 NA

* BD denotes bronchodilator, BMI body mass index, COPD chronic obstructive pulmonary disease, FEV1 1-sec forced expiratory volume, GOLD Global Initiative
for Chronic Obstructive Lung Disease, and NA not applicable
†
All P values are generated either from analysis of variance or Chi squared test, except otherwise indicated
‡
Kruskal-Wallis H
§/¶/II
Pairwise significant difference from Tukey test (§), Mann-Whitney U test with Bonferroni correction (¶) or Chi squared test with Bonferroni correction (II)

prostatic hypertrophy (23; 19%), old pulmonary the males and females were 22.1 kg/m2 and 24.0 kg/m2,
tuberculosis (18; 15%), diabetes mellitus (15; 13%), respectively. The mean 6-minute walking distances
and ischaemic heart disease (12; 10%); 95 (79%) of for males and females were 253 m and 264 m,
the patients had at least one co-morbidity. Group 3 respectively. The differences in COPD duration,
patients were significantly younger and significantly BMI, and 6-minute walking distance among the four
fewer had hypertension than in groups 2 and 4. groups were not statistically significant (Table 3).
Group 2 has the highest proportion of patients with
at least one co-morbidity, which was significantly Table 4 tabulates data on clinical management
greater than in group 3. Otherwise there was no in the four groups. In all, 22 (18%) subjects had
statistically significant difference in the demographic ever received structured COPD education. Inhaler
characteristics of the four groups (Table 2). technique was taught within the previous 6 months
to 24 (20%) subjects and within the last 2 years to 46
The mean duration of known COPD was 9.8 (38%) of them. Significantly more patients in group
years (range, 0.5-40 years). Only 12 (10%) subjects 1 had received COPD education and teaching on
had had spirometry performed in PMH within the inhaler technique within the past 2 years. In all,
last year; eight were in group 1, two in group 3, and 79 (66%) of the subjects had received influenza
two in group 4. The remaining 108 subjects had vaccination in the past, 65 (54%) in the previous year.
spirometry performed at the study visit. The mean There was no significant difference among the groups
post-bronchodilator FEV1 and % predicted values with respect to receipt of influenza vaccination. In
for males and females were 1.03 L, 45% and 0.84 L, all, 13 (11%) of the patients had received long-term
58%, respectively. Division into GOLD stages was oxygen therapy but only one (1%) was receiving non-
as follows: stage I: 10 (8%), stage II: 38 (32%), stage invasive ventilation at home. Almost all the patients
III: 46 (38%), stage IV: 26 (22%). The mean post- who received oxygen were in group 1.
bronchodilator FEV1 was significantly lower in group
1, as reflected by a significantly lower proportion Regarding drug treatment, there was more use
being stage I subjects and higher proportion being of short-acting beta agonists (SABAs) in group 3 and
stage IV. The mean body mass index (BMI) values of group 4 subjects, while more theophyllines were

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 # Treatment for chronic obstructive pulmonary disease #

TABLE 4. Treatment for stable chronic obstructive pulmonary disease

Treatment* Group 1 (n=30) Group 2 (n=30) Group 3 (n=30) Group 4 (n=30) Overall (n=120) P value†
COPD education
Ever received 13 (43%)§/¶ 2 (7%)§ 3 (10%)¶ 4 (13%) 22 (18%) 0.001
Inhaler technique taught 10 (33%) 5 (17%) 6 (20%) 4 (13%) 25 (20%) 0.241
within 6 months
Inhaler technique taught 20 (67%)§/¶/II 11 (37%)§ 8 (27%)¶ 7 (23%)II 46 (38%) 0.000
within 2 years
Influenza vaccination
Within 1 year 18 (60%) 18 (60%) 13 (43%) 16 (53%) 65 (54%) 0.552
Ever 21 (70%) 23 (77%) 15 (50%) 20 (67%) 79 (66%) 0.161
LTOT 10 (33%)§/¶/II 1 (3%)§ 1 (3%)¶ 1 (3%)II 13 (11%) 0.000‡
Home NIV 1 (3%) 0 (0%) 0 (0%) 0 (0%) 1 (1%) 1.000‡
Oral bronchodilator
Sustained-release SABA 6 (20%) 9 (30%) 22 (73%) 18 (60%) 55 (46%) <0.001‡
Theophylline 19 (63%) 12 (40%) 14 (47%) 12 (40%) 57 (48%) 0.223
Both 2 (7%)§ 3 (10%) 11 (37%)§ 8 (27%) 24 (20%) 0.010
None 7 (23%) 12 (40%) 5 (17%) 8 (27%) 32 (27%) 0.218
Mucolytic
Regular 9 (30%) 0 (0%) 7 (23%) 7 (23%) 23 (19%)
p.r.n.
None
7 (23%)§
14 (47%) } 8 (27%)§/¶/II
22 (73%) } 13 (43%)¶
10 (33%) } 10 (33%)II
13 (43%) } 38 (32%)
59 (49%)
0.016

Inhaled SABA
Regular 26 (87%) 17 (57%) 25 (83%) 17 (57%) 85 (71%) 0.008
p.r.n.
None
4 (13%)
0 (0%)
§/¶

} 13 (43%)
0 (0%)
§

} 5 (17%)
0 (0%)
13 (43%)
0 (0%)
¶

} 35 (29%)
0 (0%)
Ipratropium
Regular 21 (70%) 17 (57%) 16 (53%) 8 (27%) 62 (52%) 0.005‡
p.r.n.
None
2 (7%)
7 (23%)
§

} 2 (7%)
11 (37%)
0 (0%)
14 (47%)
1 (3%)
21 (70%)
§

} 5 (4%)
53 (44%)
Tiotropium 3 (10%) 0 (0%) 0 (0%) 0 (0%) 3 (3%) 0.058‡
LABA 15 (50%) §/¶/II
2 (7%) §
0 (0%) ¶
0 (0%) II
17 (14%) <0.001

* COPD denotes chronic obstructive pulmonary disease, LTOT long-term oxygen therapy, NIV non-invasive ventilation, SABA short-acting beta agonists, p.r.n.
according as circumstances may require, and LABA long-acting beta agonists
†
All P values are generated either from analysis of variance or Chi squared test, except otherwise indicated
‡
P value from Fisher’s exact test
§/¶/II
Pairwise significant difference from Tukey test (§), Mann-Whitney U test with Bonferroni correction (¶) or Chi squared test with Bonferroni correction (II)

used by those in group 1, though only the former Table 5 shows the breakdown on the use of
difference was statistically significant. Some form long-acting bronchodilator, inhaled corticosteroid,
of oral bronchodilator was given to 88 (73%) of the and pulmonary rehabilitation, in the four groups
patients, but there was no significant difference according to GOLD staging. Overall, long-acting
between the groups. In all, 61 (51%) of the patients bronchodilators were only given to 17 (15%) of the
received some form of mucolytic, but significantly 110 subjects in whom it was indicated (according
fewer in group 2. An inhaled SABA was prescribed to the GOLD guidelines for stages II, III, and IV).
for all patients, with regular (versus as required) use Inhaled corticosteroids were given to 49 (68%) of 72
being significantly more common in groups 1 and of stages III and IV subjects in whom it was indicated.
3. Ipratropium was increasingly used in the order: Only six patients received pulmonary rehabilitation,
group 4, group 3, group 2, and group 1, there being a three each for patients in stages III and IV. These six
significant difference between group 1 and group 4. patients comprised 5% of the 110 stages II, III, and
The use of long-acting bronchodilators (beta-agonist IV subjects in whom it was indicated. For all these
and tiotropium) was almost limited to group 1 (Table treatment modalities, group 1 received significantly
4). more prescriptions.

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 # Yu et al #

TABLE 5. Prescription of long-acting bronchodilators, inhaled corticosteroids, and pulmonary rehabilitation according to GOLD stage
Treatment* Group 1 (n=30) Group 2 (n=30) Group 3 (n=30) Group 4 (n=30) Overall (n=120) P value†
Any long-acting
bronchodilator
GOLD I 0/0 0/5 0/2 0/3 0/10 1.000
GOLD II 1/4 (25%) 0/11 0/12 0/11 1/38 (3%) 0.105
GOLD III 5/13 (38%) §/¶/II
0/9 §
0/11 ¶
0/13 II
5/46 (11%) 0.002
GOLD IV 9/13 (69%)§/¶ 2/5 (40%) 0/5§ 0/3¶ 11/26 (42%) 0.032
GOLD II+III+IV 15/30 (50%) §/¶/II
2/25 (8%) §
0/28 (0%) ¶
0/27 (0%) II
17/110 (15%) 0.000
Inhaled corticosteroids
GOLD I 0/0 2/5 (40%) 1/2 (50%) 2/3 (67%) 5/10 (50%) 1.000
GOLD II 1/4 (25%) 3/11 (27%) 5/12 (42%) 4/11 (36%) 13/38 (34%) 0.960
GOLD III 12/13 (92%)§/¶ 5/9 (56%) 5/11 (45%)§ 6/13 (46%)¶ 28/46 (61%) 0.038
GOLD IV 12/13 (92%)§ 5/5 (100%) 3/5 (60%) 1/3 (33%)§ 21/26 (81%) 0.048
GOLD III+IV 24/26 (92%)§/¶ 10/14 (71%) 8/16 (50%)§ 7/16 (44%)§ 49/72 (68%) 0.002
Pulmonary rehabilitation
GOLD I 0/0 0/5 0/2 0/3 0/10 1.000
GOLD II 0/4 0/11 0/12 0/11 0/38 1.000
GOLD III 2/13 (15%) 1/9 (11%) 0/11 0/13 3/46 (7%) 0.267
GOLD IV 3/13 (23%) 0/5 0/5 0/3 3/26 (12%) 0.575
GOLD II+III+IV 5/30 (17%) §/¶
1/25 (4%) 0/28 (0%) §
0/27 (0%) ¶
6/110 (5%) 0.011

* GOLD denotes Global Initiative for Chronic Obstructive Lung Disease

†
P value from Fisher’s exact test
§/¶/II
Pairwise significant difference from Tukey test (§), Mann-Whitney U test with Bonferroni correction (¶) or Chi squared test with Bonferroni correction (II)

Discussion Influenza vaccination is proven to reduce

COPD exacerbations, hospitalisation, and associated
The management of COPD involves proper patient serious illness and mortality.19,20 In our cohort,
assessment and monitoring, and repeated education vaccine coverage for 54% of the patients within the
about various aspects of the disease, a host of differ- preceding 1 year is suboptimal. This ensued despite
ent treatment modalities, and especially the proper intensive Government efforts (public propaganda
use of inhaled medications. Local and overseas data and incentive schemes) to boost vaccine uptake in
suggest that many patients are under-monitored and targeted populations in recent years. The medical
under-treated.4-9 Conceivably, better adherence to profession can perhaps help to disseminate the
internationally accepted treatment guidelines could beneficial effects of influenza vaccination, and
improve COPD care with a consequent reduction in encourage COPD patients to accept this important
hospitalisations including readmission rates. intervention.
Our data show that COPD subjects attending Inhaled SABAs such as salbutamol and
public sector facilities of Kwai-Tsing district are terbutaline are standard treatments for symptomatic
old, mostly males, mainly of lower social class, and COPD, and were uniformly prescribed for our
have high rate of medical co-morbidities. Moreover, subjects. Oral bronchodilators (sustained release
about half of them had severe to very severe COPD. salbutamol, terbutaline, and theophyllines) were
By and large, data on the treatment of stable COPD often given as adjuncts to inhaled therapy; their
confirmed our suspicion that there is considerable use did not differ significantly between groups.
room for improvement. First, the proportion of Conversely, inhaled ipratropium, which has proven
subjects who receive education about COPD and additive benefit on top of inhaled SABAs,21,22 was
techniques on how to use inhalers is very low. Patient more frequently prescribed in group 1 patients.
education is often part of pulmonary rehabilitation Regarding the newer and more efficacious long-
programmes and it can improve skills, ability to acting bronchodilators including long-acting beta
cope with illness, and their health status.18 Recently agonists (LABAs) such as salmeterol and formoterol
the HA has developed nurse clinics and patient and the long-acting muscarinic agent tiotropium,
empowerment programmes, which will hopefully in nearly all instances they were used in group 1
provide an impetus in this area. patients. For the prescribing of latter agents, cost

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 # Treatment for chronic obstructive pulmonary disease #

appeared to be an important consideration. However, and lung function testing at the study site. Thus, the
there is now a large body of evidence showing that diagnosis of COPD and stratification into severity
they can improve many clinical outcome parameters groups was likely to have been accurate. Another
and reduce hospital admissions,23-26 and are therefore advantage was that our study involved patients in all
cost-effective.27,28 Nevertheless, even in group 1 clinic settings and we randomly selected individuals
nearly half the patients for whom they were indicated from the different groups (except group 4) to
did not receive them. The Hong Kong data in the improve representativeness. Nevertheless, our study
EPOCA study reveal that among 153 COPD patients was designed to provide equal numbers of study
with mean FEV1 values 34% of predicted, only 2% subjects from each group, whereas the numbers
were prescribed tiotropium and 13% were prescribed of COPD patients followed up at these different
LABA/inhaled corticosteroid combinations. Both clinics were far from equal. Hence the proportion
figures were the lowest among the participating of patients with different grades of disease severity
countries.11 in each of our groups was not representative of
the actual proportions of COPD patients being
There is universal agreement on the beneficial
followed up. Also, the Kwai-Tsing population was
effects of pulmonary rehabilitation and it is generally
less than one-tenth of the total population of Hong
agreed that COPD patients in stages II, III and IV should
Kong, and our conclusions may not be applicable
receive this form of treatment.18,29,30 Disappointingly,
to other geographic areas. Future surveys should
only a very small proportion of our subjects with
be performed, based on a complete list of COPD
indications had received it. Nonetheless, under-
subjects followed up at all public and private clinics
provision of pulmonary rehabilitation appears to be a
in Kwai-Tsing, so that a truly representative sample
general phenomenon and surveys in Canada and the
can be generated. Better still, a territory-wide survey
UK showed that only 1 to 2% of the COPD population
should be performed, so as to obtain a complete
had access to it,31,32 which may be related to the need
picture of the COPD situation in Hong Kong.
for multi-disciplinary involvement and high costs.
Although group 1 subjects had more severe In conclusion, COPD patients followed up
disease, the proportion of severe and very severe at public sector facilities in Kwai Tsing had a high
disease patients in the other groups was by no means proportion of subjects with severe disease. Ideally
low (about half). Yet in these groups many patients the latter patients should have been followed up
were not prescribed long-acting bronchodilators, at respiratory units with structured COPD care
pulmonary rehabilitation and long-term oxygen programmes. More patient education and the
therapy. For pulmonary rehabilitation and long-term prescribing of long-acting bronchodilators and
oxygen therapy, it may well be that the patients are pulmonary rehabilitation appear necessary, so as to
preferentially followed up at specialist respiratory optimise their chronic care.
clinics. Though the reasons for such differential
prescribing between groups are not entirely clear, they
may be related to availability and cost considerations.
Declaration
Another possibility is that doctors in the general The study was supported by a research grant from
clinics care for a large variety of patients and may be GlaxoSmithKline Ltd.
less familiar with COPD treatment guidelines, as has
been shown in overseas studies.9,10,13,14 Interestingly,
group 1 patients had a comparable mean 6-minute Acknowledgements
walking distance to other groups, despite having We would like to thank the following persons: Ms
significantly lower mean FEV1 values. This appears to
Polly Pang and Ms Eva Tam for coordinating the
suggest that they enjoyed better overall managementstudy; Ms Carmen Cheung for performing the lung
than other groups, though our study was not function tests; Ms Candy Leung for performing the
designed to examine this possibility. 6-minute walk tests; Mr Kenny Chan for generating
Crucially, our subjects were prospectively patient lists from CDARS; and Mr WL Wong for
recruited and all attended for clinical assessment statistical support.

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