Review of Respiratory Medicine - Volumen 24, Número 1 - March 2024

Original Articles

Survey to Pulmonologists About the Choice of Guidelines for Respiratory Diseases

Encuesta a neumonólogos sobre la elección de guías de enfermedades respiratorias

ABSTRACT

Introduction: Since there are various guidelines for respiratory diseases, we aimed to know which are chosen by physicians in their daily clinical practice.

Methods: A descriptive, cross-sectional study was conducted through a questionnaire sent to pulmonologists of the Argentinian Association of Respiratory Medicine.

Results: The most commonly used guideline for COPD (chronic obstructive pulmonary disease) was the Global Initiative for Chronic Obstructive Lung Disease (GOLD) (82 %), followed by GesEPOC (51 %). For asthma, the most commonly used guideline was the Global Initiative for Asthma (GINA) 2022 (89 %) and the Spanish Guideline on the Management of Asthma (known for its acronym in Spanish, GEMA), GEMA 5.2 (68 %). In difficult-to-control asthma, GINA 2022 (82 %) and GEMA 2022 (53 %) were used. With regard to spirometries, 54 % of respondents favored NHANES III (Third National Health and Nutrition Examination Survey) and 22 % used theoretical Knudson reference values. For pneumonia, 62 % chose the guidelines of the SADI (Argentinian Society of Infectious Diseases), 37 % preferred those of the IDSA (Infectious Diseases Society of America) and 20 %, chose the guidelines of the BTS (British Thoracic Society). For pulmonary nodules, 62 % used Fleischner guidelines, and 35 % favored Lung-RADS 1.1. For hypersensitivity pneumonitis, 83 % selected the ATS/JRS/ALAT Guidelines (American Thoracic Society/Japanese Respiratory Society/Latin American Thoracic Society). And with respect to pulmonary fibrosis imaging, 89 % used ALAT/ERS (Eu­ropean Respiratory Society)/JRS recommendations, and 18 % preferred White Paper.

Discussion: Although there are studies about adherence to guidelines, none of them shows which are the chosen recommendations within a group of guidelines of the same topic. In COPD and asthma (including difficult-to-control asthma) GOLD, GINA and the guidelines of the Spanish Society of Respiratory Disease (GesEPOC and GEMA) were chosen. The preference for the national guideline for pneumonia is consistent with the need to consider local epidemiology.

Key words: Clinical Practice Guidelines, Respiratory Tract Diseases, GOLD, GesEPOC, GINA, GEMA

RESUMEN

Introducción: Dada la existencia de variadas guías para enfermedades respiratorias, se buscó conocer cuáles eligen los médicos para utilizar en su práctica clínica.

Materiales y Métodos: se realizó un estudio descriptivo, transversal, mediante una encuesta a neumonólogos de la Asociación Argentina de Medicina Respiratoria.

Resultados: La guía más utilizada para EPOC fue la Iniciativa Global para la Enferme­dad Pulmonar Obstructiva Crónica (GOLD) (82 %), seguida por GesEPOC (51 %). Para asma las más usadas fueron la Iniciativa Global para el Asma (GINA) 2022 (89 %) y GEMA 5.2 (68 %). En asma de difícil control, se prefirieron GINA 2022 (82 %) y GEMA 2022 (53 %). En espirometría, un 54 % de los respondedores se inclinó por NHANES III y un 22 % utilizó valores teóricos de referencia de Knudson. En neumonía, el 62 % eligió SADI, el 37 %, IDSA y el 20 %, BTS. Para nódulos pulmonares, el 62 % prefirió las guías Fleischner, 35 % se inclinó por Lung-RADS 1.1. Para neumonitis por hip­ersensibilidad, un 83 % seleccionó las guías de las sociedades conjuntas ATS/JRS/ ALAT. Para imágenes de fibrosis pulmonar, el 89 % utilizó ALAT/ERS/JRS/ALAT y el 18 % White Paper.

Discusión: Si bien hay estudios sobre adherencia a guías, no los hay acerca de preferencias de utilización entre varias referidas a un mismo tema. En EPOC y asma (incluyendo la de difícil control) se eligieron GOLD y GINA y las de la Sociedad Española de Patología Respiratoria (GesEPOC y GEMA). El uso preferencial de la guía nacional para neumonía es coherente con la necesidad de contemplar la epidemiología local.

Palabras clave: Guías de práctica clínica, Enfermedades respiratorias, GOLD, GesEPOC, GINA, GEMA

Received: 09/25/2023

Accepted: 02/05/2024

INTRODUCTION

Clinical practice guidelines provide a set of standards of care for the diagnosis and treatment of various diseases. The most common respiratory diseases are addressed by different guidelines, both national and international. These guidelines are periodically updated based on new evidence and are advisory in nature for practice.¹ Their recipients vary from general physicians to specialists. Although they may be thought of as opposed to personalized medicine trends, they actually complement each other since the application of a guideline is never automatic; it requires taking into account the characteristics of the patient and their context.^1,2 The guidelines them­selves are the result of systematic reviews; expert consensus is involved, both in the stage of choosing the most appropriate questions and in evaluating the results obtained and the final recommendations.³ Many medical specialty congresses dedicate part of their time to presenting, discussing, or updat­ing them, contributing to their dissemination and eventual use.

From the Clinical and Critical Care Section of the Argentinian Association of Respiratory Medi­cine (AAMR), we aim to understand which are the specialty guidelines chosen by pulmonologists as­sociated with the AAMR.

MATERIALS AND METHODS

A cross-sectional study was conducted through an anon­ymous survey of the physicians who are members of the AAMR. A questionnaire was designed using a form on the Survey Monkey^© platform which included questions about the characteristics of the physicians and their use of pulmonology guidelines. The researchers selected the most widely disseminated guidelines for relevant respiratory diseases and other respiratory topics (Table 1) based upon their criteria. The survey allowed respondents to select more than one guideline for each topic, because in practi­ce, physicians make use of elements from one guideline or another, according to their needs.

With the agreement of the AAMR authorities, 946 active members of the updated roster of pulmonologists as of Octo­ber 25, 2022 were invited to participate via email. Between October 25 and December 15, 2022, the questionnaires were sent out initially and resent up to a maximum of four times to those who did not respond.

The analysis was conducted using Stata 16.0 software (StataCorp, Texas, USA). Groups were compared using the chi-square test or Fisher’s exact test, as appropriate. A p-value of <0.05 was considered significant.

RESULTS

318 completed forms were obtained, resulting in a response rate of 33.61 %. The characteristics of the sample are presented in Table 2.

A higher proportion of women was found among respondents under 50 years of age. 59.26 % (n = 96) of the 162 respondents under 50 years of age and 40.38 % (n = 62) of the 156 respondents aged 50 or older were women. This difference was statistically significant (p = 0.001).

Although the public sector as the sole work­place was underrepresented, women and respon­dents under 50 years of age were predominant in that sector. 73.33 % (n = 22) of the 30 respon­dents who worked solely in the public sector, 43.75 % (n = 49) of the 112 who worked in the private sector, and 50 % (n = 88) of the 176 who worked in both sectors were women (p = 0.016). Similarly, 66.67 % (n = 20) of the 30 respondents who worked solely in the public sector, 39.29 % (n = 44) of the 112 of the private sector, and 55.68 % (n = 98) of the 176 respondents who worked in both sectors were under 50 years of age (p = 0.005).

It was common for the respondents to select more than one guideline for each condition. Table 3 shows the reported frequency of use for each guideline.

In COPD, the most commonly used guideline was the GOLD (82 %), followed by GesEPOC (51 %); and the least consulted was the one from the Ministry of Health of the Nation (8 %). For asthma, the most frequently chosen guidelines were GINA 2022 (89 %), GEMA 5.2 (68 %), NICE (7 %), and NAEPP (2 %). In difficult-to-control asthma, GINA 2022 (82 %) and GEMA 2022 (53 %) were mostly used. In relation to spirometries, 54 % of respondents chose NHANES III and 22 % used theoretical Knudson reference values. For pneu­monia, 62 % chose the guidelines of the SADI, 37 % preferred those of the IDSA and 20 %, chose the BTS. For pulmonary nodules, 62 % of respondents used Fleischner guidelines, and 35 % favored Lung-RADS 1.1. For hypersensitivity pneumonitis, 83 % selected the ATS/JRS/ALAT Guidelines, and 25 % chose the AACP (American Association of Chest Physicians). Regarding pulmonary fibrosis imaging, 89 % used ALAT/ERS/JRS recommenda­tions, and 18 % preferred White Paper.

Table 4 compares the use of guidelines across groups according to gender.

There were no differences across the groups according to gender in the frequency of use of most guidelines, with the exception that women reported a higher frequency in the use of the GINA guidelines for asthma.

Table 5 compares the use of guidelines across groups according to age.

Individuals under the age of 50 reported a sta­tistically significant higher usage of the GOLD and GesEPOC guidelines for COPD, the GINA and GEMA 5.2 guidelines for asthma, the GLI 2012 guideline for spirometry, the ATS/IDSA 2019 guideline for pneumonia, and the Fleischner Society 2018 and ACCP 2021 (Chest) guidelines for hypersensitivity pneumonitis incidental nod­ules. Regarding spirometries, the group over 50 reported higher use of Knudson’s theoretical reference values.

Table 6 compares the use of guidelines across groups according to the work environment.

There were no significant differences in the groups that were divided according to work envi­ronment with regard to the frequency of use of the guidelines for COPD, asthma, difficult-to-control asthma, spirometry, pneumonia, hypersensitivity pneumonitis, or lung fibrosis imaging. Regarding lung nodules, the Fleischner guideline was most frequently used in the public sector.

DISCUSSION

This research is novel as we have not found any literature that considers usage preferences among different guidelines for respiratory diseases in our setting. The diseases under consideration by the respondents reflect the frequency of these diseases in consultations to pulmonologists. A study con­ducted in a general population over 40 years of age from six major regions of Argentina (EPOC.AR), which included the performance of spirometries, revealed a prevalence of COPD of 14.5 %.²³ Asthma is one of the most prevalent respiratory diseases in Argentina and worldwide.²⁴ In urban areas of our country, a telephone survey among individuals aged 20 to 44 identified 5.9 % of 1,521 subjects as asthmatic, while 13.9 % reported having wheez­ing.²⁴ Additionally, it is known that around 5 % of the asthmatic population suffers from severe forms of this condition.²⁵ Given the need to perform spirometries for the diagnosis and monitoring of these and other conditions, it was considered in­teresting to explore whether pulmonologists used the same equations for their reference values when reporting them.

There are numerous publications related to levels of adherence to pulmonology guidelines, many of them in their early versions. This study addresses another aspect, the preference for one guideline to another, in the context of Argentina, at a time when many of those guidelines are well-established and some refer to the same topics, thus providing the possibility of choice.

In COPD, the GOLD guideline dates back to 2001, with annual updates and major revisions every 5 years. It is developed by an international panel of healthcare professionals that includes experts in respiratory medicine, public health, education, and economics, among other things.²⁶ Its development responds to the need for a strate­gic document to provide effective care for COPD patients globally. An update from 2023 is avail­able with changes in the classification and some therapeutic strategies, along with a review of the COVID-COPD association chapter.²⁷ On the other hand, the first version of the GesEPOC guideline was published in 2012.²⁸ While not substantially different, the development team of GesEPOC includes members of the Spanish Patients Forum; it proposes a multidimensional evaluation, and is one of the first guidelines to conduct treatment ac­cording to clinical phenotypes.²⁸ The latest updates incorporate the concept of treatable traits, which would allow for a more personalized approach to medicine. As for the national guideline from the Ministry of Health, it was developed in 2017, it has not been updated since then, and has not been widely disseminated.⁶ In this study, the GOLD Guideline was reported as the most commonly used guideline for COPD (82 %), followed by GesEPOC (51 %); and the least consulted was the one from the Ministry of Health of the Nation (8 %). In individuals under 50 years, the frequency of use of GOLD and GesEPOC was significantly higher, but there were no differences according to the pro­fessionals’ work environment. A study conducted among generalist physicians from two New York hospitals identified barriers to implementing the GOLD 2010 guideline.²⁹ The difficulties cited by professionals for not adhering to GOLD guidelines included lack of familiarity, perceived low benefit, time limitations, and occasionally, disagreement.²⁹

In asthma, the GINA guideline dates back to 1995, with annual updates since 2002.³⁰ The most recent updates include a significant change in the management of mild asthma, the first of the five treatment steps, which relegates short-acting beta 2 agonists (SABAs) to alternative rather than sug­gested treatment for exacerbations. The GEMA guideline, whose first edition dates back to 1997, recognizes six therapeutic steps and, although it allows for combined treatment with inhaled corti­costeroids, it maintains the use of SABAs as rescue medication; there is a more detailed breakdown of the treatment for severe forms in step 6.³¹ The NICE guideline, of British origin, has a wide range of recipients (generalist physicians, nurses, pro­fessionals in secondary and tertiary care services for asthma, patients, and families, among others) and is organized based on a thematic index.⁹ The NAEPP guideline, of American origin, is aimed at professionals and is presented in the form of ques­tions, for which answers are given with their level of evidence and recommendations. ¹⁰ It allows for a focused consultation for a specific problem in the practice. In the present study, the most reported guidelines were GINA 2022 (89 %) and GEMA 5.2 (68 %), and respondents under 50 years were the ones who chose them the most. A joint statement by the ERS and the European Academy of Allergy and Clinical Immunology (EAACI) warned about suboptimal adherence to these guidelines inter­nationally and emphasized the need to consider different real-life contexts.³²

In difficult-to-control asthma, GINA 2022 (82 %) and GEMA 2022 (53 %) were mostly used. While patients are usually assisted in reference centers, respondents report using the same gen­eral asthma guidelines (GINA and GEMA). There are also guidelines for difficult-to-control asthma developed by ALAT, which is one of the societies incorporated into the GEMA guidelines, that is why they were not specifically consulted in this survey.³³

Regarding reference equations for spirometry, the use of one or the other can affect the diagnosis of airway obstruction and the estimation of its se­verity.³⁴ One of the oldest, the Knudson equation, was based on a North American white population; 746 patients aged 8 to 90, and emerged to detect diseases in textile workers due to cotton expo­sure.³⁵ It was later expanded to include African Americans but not Latin Americans. In 2005, the ATS and ERS recommended the use of the equa­tion known as NAHNES III for US patients aged between 8 and 80 years.³⁴ In order to extend the reference to other groups, the GLI 2012 included 57,395 Caucasians, 3,545 African Americans, and 13,247 Asians; the age range extended from 3 to 95 years.¹² These last two equations have shown good correlation with each other for average adults, which is not the case when dealing with patients older than 80 years, particularly those of extreme heights (very short or very tall).³⁴ A study conducted in Chile included the comparison of the Knudson equation (the most commonly used by laboratories in that country) with the Gutiérrez 2014 equation (designed for the Chilean popula­tion) and GLI 2012, in 315 subjects over 40 years, smokers or ex-smokers, healthy or with COPD, and found good correlation between the three.³⁶ It has been suggested that the Knudson equation underestimates restriction compared to NHANES III.³⁶ In Argentina, functional measurements were performed on 105 women and 132 men from the Capital City and Metropolitan Area of Buenos Ai­res, between 18 and 86 years old, and the Lower Limit of Normality (LLN) was determined as a variable percentage for each parameter, at each age, and at each height, thus eliminating the concept of a fixed percentage value, which led to underdiagnosis in younger individuals and over­diagnosis in older ones.³⁷ In Mendoza, a similar study was carried out on 103 healthy volunteers, aged 15 to 65 years, who underwent spirometry, and a smaller number underwent peak expiratory flow, measurements of mean inspiratory and expi­ratory pressures (MIP and MEP), and a 6-minute walk test.³⁸ Good correlation was found between NHANES and the Mendoza sample, especially in spirometric values, except for the FEV1/FVC ratio (forced expiratory volume in the first second/forced vital capacity) where the LLN was a better option for defining normality.³⁸

In our work, the most commonly used equation was NHANES III, which may be related to the fact that most spirometry equipment has it incor­porated into their software. The increased use of the GLI equation among young people could be explained by the fact that it includes multiethnic groups, has a wider age range (3 to 95 years), and was gradually included in new equipment.¹² Con­versely, the use of the Knudson equation, which is used by one-fifth of the respondents, predominates among those over 50 years and may be attributed to the age of the equipment or to the lesser flexibil­ity in adapting to changes found in this age group.

In pneumonia, the national guideline of SADI was the most commonly used among our respon­dents, despite not being updated since 2014. This is attributed to the fact that, it being an infec­tious disease, local epidemiological factors and available antibiotics in our country are taken into account as well as being more user-friendly due to its concise nature and for being in the Spanish language. Gatarello et al studied the adherence of respondents to the IDSA/ATS pneumonia guide­line and included 36 Latin American physicians.³⁹ Treatment was considered appropriate in 30.6 % of prescriptions for community-acquired pneumonia. The use of antibiotics with inadequate spectrum, monotherapy, or coverage not indicated for multi­drug-resistant organisms was considered as lack of adherence. In the case of nosocomial pneumonia, compliance with the IDSA/ATS guidelines was only 2.8 % (monotherapy and lack of dual antibiotic treatment against Pseudomonas aeruginosa).³⁹

Regarding pulmonary nodules, the most fre­quently chosen guideline was the Fleischner Society 2018, which was developed for the man­agement of incidental nodules, that is to say, those appearing during a chest CT scan for any requested reason.¹⁷ Its goal is to limit further evaluations of nodules with very low probability of cancer (<1 %) and not overlook them if the probability is ≥1 %.¹⁷ Hedstrom et al studied the adherence of radiologists and clinicians to the Fleischner Society guidelines with regard to the management of incidental lung nodules and found that around 5 % conducted a more aggressive follow-up and in 9 % of the cases, the follow-up was less aggressive than recommended.40 In contrast, Lung-RADS is oriented towards the management of nodules found during screening, corresponding to indi­viduals with sufficient risk to qualify for these programs.¹⁸ Moreover, the number of centers cur­rently conducting screening in our country is not high, hence the lower familiarity with Lung-RADS.

When analyzing guidelines for hypersensitivity pneumonitis, a clear preference is observed for the 2020 ATS/JRS/ALAT guidelines. Its dissemination during the pandemic and its temporal precedence over the ACCP guidelines could explain this choice. Among those who chose the ACCP guidelines, the ones under 50 years prevailed. As already men­tioned, the study protocol allowed for opting for more than one guideline, according to the needs.

With regard to the images supporting the diag­nosis of pulmonary fibrosis, the use of ALAT/ERS/ JRS was predominant, and this can be attributed to its wider dissemination and the fact of hav­ing been elaborated by multiple societies, which provides more robustness. However, there are no major differences between these guidelines and the Fleischer Society White paper. Both identify key questions and provide radiological and tissue images that are prototypical of each proposed category. The latter adds a checklist at the end to rule out alternative diagnoses.

Several authors of hypersensitivity pneumonitis and pulmonary fibrosis guidelines warn in a recent publication that, as each guideline is developed independently, they do not reflect the physician’s needs when faced with a patient who does not yet have a diagnosis and is within a spectrum of fi­brotic diseases that may include both conditions.⁴³ With a pragmatic approach, they suggest using an algorithm that integrates these two guidelines and includes both clinical, radiological, and pathologi­cal features to distinguish hypersensitivity pneumonitis from pulmonary fibrosis.⁴¹

In general terms, although respondents were not asked to justify their choice, it can be specu­lated that professionals’ preference for different guidelines is due to the fact that they were origi­nated from well-known societies, which respond to a rigorous and updated review of the best available scientific evidence. In the case of the Argentine guideline on pneumonia, the local relevance of the recommendations is privileged. Another factor that may determine the choice is the availability of the equipment or supplies suggested in the stan­dards, because if they are not available, the guide­line is less applicable. Finally, once professionals become familiar with one particular guideline and have experience with it, they incorporate updates more naturally.

This study acknowledges limitations, mainly the number of respondents, given that only 33 % of those who received the survey responded. It was conducted among pulmonology specialists from the AAMR, excluding other specialties or pulmonolo­gists not associated. There is also the limitation of having omitted some guidelines that are possibly used. Recently, the ERS/ESICM (European Society of Intensive care Medicine)/ESCMID (European Society of Clinical Microbiology and Infectious Diseases)/ALAT have released a guideline for the management of severe community-acquired pneu­monia, which has not been part of our survey.⁴²

However, their results allow us to explore the current reality regarding the use of the guidelines and make some general recommendations. The need to use updated guidelines is emphasized, as this improves the quality of care, increases patient safety, provides legal and juridical support for professionals, and optimizes cost-effectiveness. Scientific societies together with national health authorities should encourage guideline update and availability. Likewise, treatments proposed with strong evidence should be available in the country, avoiding dissociation between recommendations and daily practice. Referring specifically to one of the guidelines subjected to the survey in this research, we suggest that the GLI spirometric reference equation is used in our equipment, for the advantages mentioned before. Similarly, it would be of high priority to update the national guideline for acute community-acquired pneumo­nia, with the participation of all societies involved in its management.

In conclusion, an analysis of the situation has been described as of the end of 2022 regarding the use of guidelines for prevalent respiratory diseases by a group of 318 pulmonologists who are members of the AAMR. Although there is a trend among respondents under 50 to use the most recent guidelines, the use of updates from long-standing guidelines of the main scientific societies in the specialty, such as GOLD in COPD, GINA in asthma, and SADI in pneumonia, remains very strong in all groups.

Acknowledgement

To the authorities of the AAMR, to the secretaries of the AAMR, and the webmaster Muriel Cabrera.

Conflict of interest

The authors have no conflict of interest to declare that are relevant to this publication.

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