The GOLD Global COPD Diagnosis and Treatment Strategy Report recommends that all patients should take at least one drug during the stable phase of COPD to obtain symptomatic relief and reduce the incidence of adverse outcomes16. The standardised use of inhaled drugs is the first choice of treatment among patients with COPD, as these drugs can considerably improve clinical symptoms and prognosis in patients with moderate/severe COPD17. By contrast, insufficient treatment heightens the likelihood of acute exacerbations18. Therefore, if conditions permit, inhalation therapy can be more effective than oral therapy; however, this has not been observed in the actual clinical setting. More than one-third of patients with COPD in Spain do not adhere to the 2017 GOLD guideline recommendations7. A Swiss study on the implementation of GOLD by GPs in community healthcare settings showed that 44% of patients with COPD did not comply with the GOLD-recommended treatment regimen, and the compliance rate of GPs to implement GOLD was low19. A retrospective study of patients with COPD from northern Italy reported that only 38.7% of patients were receiving treatment20. Another study showed that only about 30% of patients with COPD were treated in accordance with the guidelines. According to the comprehensive assessment, the consistency with the guidelines was 20.6% in group A, 32.3% in group B, 5.9% in group C and 39.2% in group D21. Similar findings were reported in studies from other countries22,23.

Only a few studies have focused on the pharmacotherapy of patients with COPD in China. Liang et al.24 reported that less than 20% of patients with COPD in China adhered to the drug therapy after discharge, and Wang et al.12 indicated that the consistency between drug therapy and guidelines was less than 3.5%. There has been a slight increase in the number of reports on the pharmacotherapy of patients with COPD in recent years. Chen et al.13 reported that 10.8% of patients with COPD were highly adherent to the drug therapy (PDC ≥ 0.8) during the 12-month follow-up management. Another study focused on medication adherence among patients with COPD in China found that only 33.2% of patients adhered to medication at 1-year follow-up25. A recent COPD study showed that 27.7–35.4% of patients in tertiary hospitals and 28.9–36.4% of patients in secondary hospitals accepted ICS/LABA; further, 18.3–19.5% and 22.1–24.6% patients in tertiary hospitals and 12.5–12.6 and 12.2–13.7% patients in secondary hospitals received LAMA monotherapy and ICS/LABA + LAMA, respectively. Moreover, the proportion of patients receiving the above treatment regimens was almost the same at 1-year follow-up14. At present, limited literature is available regarding the management of COPD by general practitioners.

This study collected real data on COPD management by GPs through MICCOPD. Out of the total 2044 patients diagnosed with COPD, only 814 individuals (39.8%) were prescribed an initial medication regimen. During the 2 consecutive years of 814 patients follow-up management, the drug treatment compliance rates of patients were 45.7%, 38%, 31.6% and 14.6% at 6, 12, 18 and 24 months, respectively. Patients adherence to drug treatment tended to decline annually. Despite initial adherence to drug regimens consistent with the guidelines, patient adherence to drug therapy declined during subsequent follow-up visits. According to the guidelines for the prevention and treatment of COPD by the China Respiratory Community Alliance26, patients with newly diagnosed COPD must be diagnosed again by specialists, and the diagnosis and treatment plan should be formulated before they can be prescribed in the community, which affects the diagnosis and treatment of patients who cannot visit the specialist’s clinic in time. Furthermore, a considerable proportion of patients with COPD lacked awareness of the seriousness of their condition and had limited knowledge regarding preventative measures and treatment options27. This lack of knowledge may lead to premature discontinuation of prescribed medications, particularly among individuals experiencing mild dyspnea symptoms in stable environments. These patients may be reluctant to seek further care from respiratory specialists. In addition, some patients may decline participation in specialized treatment programs owing to concerns about reliance on inhaled medications. Our study findings indicate that patients who adhered to medication were typically older, with frequent hospitalizations and severe illness.

The results showed that 35.9% and 41.9% of patients inhaled bronchodilators and took oral bronchodilators as the initial drug treatment, respectively. The overall initial treatment compliance with the 2017 GOLD guidelines was only 35.5% in this study, whereas 49.1% and 15.4% of the patients were under- and over-treated, respectively. A considerable proportion of COPD patients in groups A and B were prescribed ICS + LABA inhalers, which was a deviation from the GOLD2017 guidelines and indicative of overtreatment. Conversely, the initiation of recommended inhalation therapy was delayed in patients in groups C and D, who opted for intermittent oral medications instead, leading to inadequate treatment outcomes. Over- and under-treatment are also common clinical problems. In a Swiss study, 53% of the patients were not taking medications consistent with the 2017 GOLD recommendations. In that study, 87.1%, 37% and 47.5% of the patients in GOLD groups A, B and C, respectively, were over-treated, whereas 15.2% of the patients in GOLD group D were not receiving adequate treatment according to the 2017 GOLD guidelines6. A study of patients with COPD in Canada who did not adhere to recommended treatment regimens revealed a prevalent lack of implementation28. Factors contributing to the non-adherence in low-risk patients included female gender, high socioeconomic status, long COPD duration, increased comorbidities, presence of dementia, history of mental health conditions and old physician age. Factors contributing to non-adherence in high-risk patients included advanced age, multiple comorbidities, cognitive impairment, heart failure, psychiatric disorders and the age of the treating physician. However, individuals at high risk were inclined to adhere to prescribed medications, possibly owing to a shared goal between healthcare providers and patients to effectively manage the condition and mitigate disease severity.

In patients who adhered to medication, the percentage of patients whose medication aligned with the recommended treatment plan was 35.5% at 0.5 years, 32.7% at 1 year, 35.4% at 1.5 years and 37.0% at 2 years. The overall proportion of patients who adhered to the recommended treatment plan was relatively stable. Under- and over-treatment also persisted during the follow-up period, with no considerable improvement. The persistent lack of adherence to the guidelines may be owing to the lack of community practitioner adherence to the guidelines. General practitioners may not promptly modify drug regimens based on patient symptoms, particularly in elderly patients with COPD with comorbidities, which may diminish patient survival rates. Analysis of a survey administered to general practitioners in primary care settings in Sweden and Canada revealed notable deficiencies in understanding multiple facets of COPD diagnosis and treatment and substandard adherence to the 2017 GOLD guidelines29,30. In addition, we previously demonstrated that knowledge about COPD prevention and management among general practitioners was insufficient31. Various factors impact medication adherence in patients with COPD, highlighting the importance of improving general practitioner training and adherence to COPD guidelines, enhancing professional competence and fostering better communication between patients and healthcare providers, including doctors and pharmacists.

COPD is a chronic disease, and long-term adherence to standardised drug therapy is crucial for its prevention and treatment. Every patient with COPD hopes to control their symptoms as soon as possible and reduce the number of acute exacerbations in the future. This study showed that adherence to drug therapy for a long duration could improves CAT scores, mMRC classification grade and the number of hospitalisations. During 2 years of follow-up, the proportion of patients in group D tended to decrease compared with the initial data. Various domestic and foreign studies have shown that the compliance rate of patients with COPD with drug therapy is 40%–60%, and the consistency between the actual drug therapy and guidelines fluctuates between 25% and 48%. The results of our study suggested that the consistency of medication adherence with the guidelines in Shanghai Songjiang was better than those reported in previous studies conducted in China12. Nevertheless, several obstacles to the effective management of COPD during the stable phase remain. Treatment adherence and alignment of drug treatment regimens with guidelines have not been optimized and lag behind the COPD management practices in developed countries. The prevention and treatment capabilities of general practitioners should be enhanced. In addition, we propose adjustments to the basic guidelines to grant qualified general practitioners the authority to prescribe initial treatment for COPD. This measure could expedite drug treatment for a greater number of patients. The combination of general practitioner–specialist doctor–patient prevention and treatment should be strengthened pharmacists, nurses and prevention healthcare professionals should cooperate to improve the compliance with standardised drug treatment in patients with COPD.

Our study has several limitations. First, this is a retrospective cohort study. Second, as all patients were from Shanghai, they cannot represent the general situation in China. Third, the study could not capture the fluctuating changes in pulmonary function throughout the follow-up period owing to limitations related to community-based pulmonary function testing. Finally, due to the outbreak of the coronavirus disease 2019 pandemic in 2020, this study only included data collected during the 2-year follow-up after registration to the platform. Hence, in future studies, the MICCOPD platform will be used to collect pulmonary function data and health economics data from follow-up patients to establish a solid groundwork for improving patient treatment adherence and standardised care aligning with the guidelines. However, challenges in COPD management during stable periods persist. Consequently, further research is warranted to explore and address these challenges.

In summary, based on the MICCOPD, the compliance and guideline consistency rates among patients with COPD in the community who were managed by GPs are higher than those previously reported in China; however, there is still a big gap compared with developed countries. Compliance was more common in male patients, patients with poor lung function and patients with more emergency department admissions. The number of acute exacerbations, decrease in comprehensive assessment grade, and symptoms in patients with COPD can be improved by ensuring adherence to the drug treatment. Enhancing general practitioner proficiency in the prevention and management of COPD and increasing patient awareness of the condition are crucial for standardising and improving adherence to initial and follow-up COPD treatments.