Is the new GOLD classification applicable in China?
Authors: Ning Shen, Bei He
Journal: The Lancet Global Health (2013)

Chronic obstructive pulmonary disease (COPD) remains a major public health problem. The Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease was first published by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) in 2001. A major revision was undertaken in 2011 and an update to it was published in February this year.1Global Initiative for Chronic Obstructive Lung Disease (GOLD)Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: revised 2011.http://www.goldcopd.org/uploads/users/files/GOLD_Report_2013_Feb20.pdfGoogle Scholar The Chinese Society of Respiratory Disease recently released new Chinese COPD guidelines,2Chinese Society of Respiratory DiseaseThe guideline for the diagnosis and treatment of chronic obstructive pulmonary disease.Zhonghua Jie He He Hu Xi Za Zhi. 2013; 36: 255-264Google Scholar which recommend that the same strategy is used in China. However, whether this new system proves to be an improvement on the old system and whether it is applicable in China remains controversial and needs further research. Many differences exist between China and the developed countries that most of the GOLD committee members come from. 4·3 million people in China have COPD, and the disease prevalence is significantly higher in rural (8·8%) than in urban areas (7·8%; p=0·007).3Zhong NS Wang C Yao WZ et al.Prevalence of chronic obstructive pulmonary disease in China.Am J Respir Crit Care Med. 2007; 176: 753-760Crossref PubMed Scopus (625) Google Scholar 36·4% of practising Chinese doctors work at basic medical facilities (including community health service centres, small rural hospitals, village health rooms, clinics, and nurses' stations). The educational level of these doctors is worrying. Of licensed doctors, only 8·3% have a post-graduate degree and 43·6% have a bachelor's degree. Thus, nearly half of all doctors in China have quite a low level of education, and the situation for licensed assistant doctors is even worse.4National Health and Family Planning CommissionChina Health Statistical Yearbook.http://www.moh.gov.cn/htmlfiles/zwgkzt/ptjnj/year2011/index2011.htmlDate: 2011Google Scholar Use of the GOLD criteria in China encounters several problems, as outlined below. The assessment of symptoms in patients with COPD is based on either the modified Medical Research Council (mMRC) or the COPD Assessment Test score. In GOLD 2013, the Clinical COPD Questionnaire is also introduced. In clinical practice in China, 40–80 patients are seen per doctor per day, without enough nurses or physician assistants to help. Therefore, whichever is the easiest method to assess symptoms is judged to be the best. In one of our studies5Zhou QT Mei JJ He B et al.Chronic obstructive pulmonary disease assessment test score correlated with dyspnea score in a large sample of Chinese patients.Chin Med J. 2013; 126: 11-15PubMed Google Scholar we enrolled 6437 patients in 329 hospitals across China and found that the COPD Assessment Test score was moderately correlated with mMRC dyspnoea grade (r=0·579, p<0·001). The most practical approach is for physicians to ask only one question—"do you feel breathless when walking?"—and quickly obtain the mMRC score. Therefore, use of only mMRC might be suitable for Chinese clinical practice. Spirometry is needed to diagnose COPD in the new GOLD 2011 criteria and spirometric tests are always important in the assessment of the disease. However, spirometry is not correctly or widely used in China. He and colleagues6He QY Zhao Q Ye RJ et al.Preliminary investigation on lung function test in diagnosis of chronic obstructive pulmonary disease in some provinces and cities of China.Zhonghua Jie He He Hu Xi Za Zhi. 2003; 26: 39-40Google Scholar reported that only 50% of patients with COPD had ever had spirometry tests in tertiary hospitals, and only 18% had in primary or secondary hospitals. In our epidemiological survey in a rural area of Beijing,7Shen N Yao WZ Zhu H Patient's perspective of chronic obstructive pulmonary disease in Yanqing county of Beijing.Zhonghua Jie He He Hu Xi Za Zhi. 2008; 31: 206-208PubMed Google Scholar none of the 148 patients with COPD had ever undergone spirometry. This situation is due to inadequate physician knowledge about the disease and a scarcity of equipment in lower-level hospitals. A solution could be to use different methods in different hospitals. Although the GOLD criteria are suitable for use in tertiary hospitals, other methods such as peak expiratory flow rate could be used instead in primary or secondary hospitals, since their sensitivity and specificity are quite good.8Jackson H Hubbard R Detecting chronic obstructive pulmonary disease using peak flow rate: cross sectional survey.BMJ. 2003; 327: 653-654Crossref PubMed Scopus (77) Google Scholar The risk of exacerbation can be assessed in several ways: symptoms, use of medication, and admission to hospital. However, several questions remain to be answered in Chinese clinical practice. For example, the time of an acute exacerbation is often inaccurate because many patients have a poor understanding of the disease,7Shen N Yao WZ Zhu H Patient's perspective of chronic obstructive pulmonary disease in Yanqing county of Beijing.Zhonghua Jie He He Hu Xi Za Zhi. 2008; 31: 206-208PubMed Google Scholar, 9Lou P Zhu Y Chen P et al.Vulnerability, beliefs, treatments and economic burden of chronic obstructive pulmonary disease in rural areas in China: a cross-sectional study.BMC Public Health. 2012; 12: 287-293Crossref PubMed Scopus (43) Google Scholar and they might be unwilling or unable to write a COPD diary. Changes in medication, such as use of short-acting β2-agonists, antibiotics, or oral corticosteroids, might be strongly affected by the knowledge of the physicians and the financial situation of the patients. In our study,7Shen N Yao WZ Zhu H Patient's perspective of chronic obstructive pulmonary disease in Yanqing county of Beijing.Zhonghua Jie He He Hu Xi Za Zhi. 2008; 31: 206-208PubMed Google Scholar none of the stable patients with COPD took inhalers regularly or as needed. During acute exacerbations, only 6·8% took theophylline and 6·8% antibiotics. Another Chinese study9Lou P Zhu Y Chen P et al.Vulnerability, beliefs, treatments and economic burden of chronic obstructive pulmonary disease in rural areas in China: a cross-sectional study.BMC Public Health. 2012; 12: 287-293Crossref PubMed Scopus (43) Google Scholar reported similar results. However, in China, patients can obtain antibiotics easily. Many people keep antibiotics in reserve at home and they tend to show a preference for these drugs. Thus, use of antibiotics does not always indicate an acute exacerbation. Finally, the indication of hospital admission varies in different hospitals, and is affected by socioeconomic factors, the health system, and policy. Inhaled corticosteroids, long-acting β-agonists, and long-acting muscarinic agonists are all expensive drugs and many patients in China cannot afford them. An alternative pharmacological treatment for COPD, phosphodiesterase-4 inhibitor, is awaiting approval by the China State Food and Drug Administration. In our 2008 study,7Shen N Yao WZ Zhu H Patient's perspective of chronic obstructive pulmonary disease in Yanqing county of Beijing.Zhonghua Jie He He Hu Xi Za Zhi. 2008; 31: 206-208PubMed Google Scholar only 4·1% of stable patients with COPD took theophylline, and did so irregularly. Despite the fact that this study was done 5 years ago, the present situation is still not optimistic. Although most people living in rural areas have joined the New Rural Co-operative Medical System of China, the proportion of reimbursement is quite low. For example, the reimbursement for admission to hospital is only 30% for tertiary hospitals and 40% for secondary hospitals in many regions. Thus, only patients with a high standard of living and a high level of education can follow the guidelines. We should have our own guidelines with patient stratification, and assessment of theophylline, carbocysteine, and other alternative drugs to make them more applicable in China. A basic version of treatment for COPD could be introduced (and would exist alongside the standard treatments), which would enable more general doctors to use available methods of diagnosis and treatment, and give patients in rural or remote areas the opportunity to have affordable and appropriate treatment. In conclusion, the GOLD 2011 criteria and the new COPD guidelines in China enable a better understanding of the effects of the disease. However, the applicability of the GOLD criteria in China is still questionable. Perhaps future guidelines will expand these concepts by taking into account the characteristics of developing countries, and will be modified according to local clinical practice in different countries. We declare that we have no conflicts of interest.