Background: The 2023 Global Initiative for Chronic Obstructive Lung Disease (GOLD) update reclassified patients with chronic obstructive pulmonary disease (COPD) into group E based solely on exacerbation history, regardless of symptom burden. However, there are limited real-world descriptions of these patients at high risk of future exacerbation. This study therefore characterized patients in GOLD E, including subgroups based on blood eosinophil count (BEC), triple inhaler therapy use, and smoking status. Methods: Retrospective analysis of administrative claims and electronic health records obtained from Optum’s Market Clarity Dataset between 2016 and 2021. Adults aged 40– 80 years with COPD and continuous enrollment were observed for three years. Year 1 (baseline) included the earliest evidence of COPD. GOLD E status was defined as ≥ 2 moderate or ≥ 1 severe exacerbation during baseline. Results: Of 145,341 patients with COPD, 38,648 (26.6%) met GOLD E criteria. Patients in GOLD E had a higher prevalence of comorbidities (including cardiovascular-related conditions), elevated BEC (≥ 300 cells/μL), triple inhaler use, and former smoking status, compared with non-GOLD E. Approximately 58.2% of patients in GOLD E had evidence of a BEC test. Despite treatment recommendations, only 14.2% of patients in GOLD E with elevated BEC used triple inhalers. Notably, 34.8% of GOLD E had no evidence of any maintenance medication use. Of those with known smoking status (65.6%), current smokers had fewer severe exacerbations than never or former smokers. However, current smokers were 4.5– 5.5 years younger, had lower prevalences of obesity and cardiovascular comorbidities, and the highest use of rescue medications—factors that help explain this unexpected result. Conclusion: Many patients in the United States with COPD in GOLD E were not treated according to recommendations, and BEC testing remains underutilized. Exacerbation rates were high, even among never or former smokers with COPD. Plain Language Summary: Among all patients with COPD, those in Group E of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) classification system experience the most frequent exacerbations. Patients in GOLD E also face the highest risk of future exacerbations. These events are associated with increased mortality, patient burden, and health care costs. However, there remains a lack of research on the demographic, clinical, and treatment characteristics of this high-risk group. Accordingly, this retrospective study used 12 months of insurance claims data to help payers and clinicians better understand these patients and their unmet needs. Results showed that 38,648 patients in GOLD E had a higher prevalence of comorbidities (eg, asthma, cardiovascular disease, hypertension), and elevated blood eosinophil count (BEC ≥ 300 cells/μL), compared to 106,693 patients with COPD but not in GOLD E. The proportion of current smokers was similar between GOLD E and non-GOLD E. Importantly, many patients in GOLD E were not treated according to recommendations. For example, 34.8% of GOLD E had no evidence of any maintenance medication, and only 14.2% with BEC ≥ 300 cells/μL used the recommended triple inhaler therapy. Because both moderate and severe exacerbations are associated with increased risk of disease progression, economic burden, and mortality, they should be addressed early—even among never or former smokers. Keywords: COPD, disease burden, eosinophilic COPD, exacerbations, tobacco smoking, type 2 inflammation
Bhatt et al. (Sun,) studied this question.