Incident COPD in Belgian primary care: Exacerbation profiles, treatment patterns and opportunities to advance guideline concordant care

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality worldwide. International guidelines emphasize individualized care and timely treatment escalation, but evidence on local real-world implementation in primary care is limited. This is a secondary data analysis of Intego, a Flemish primary care registry comprising anonymized electronic health records from 108 practices. Adults aged ≥40 years with a first-ever COPD diagnosis between January 2022 and December 2023 were included. Outcomes were initial pharmacological treatment, escalation to triple therapy after moderate exacerbations, and documentation of key clinical parameters and vaccinations. Among 1789 patients (mean age 67 years; 46.5% female), 44% experienced ≥1 exacerbation and 8.3% were frequent exacerbators (mean follow-up of 1.56 years). All-cause mortality was 8.9%, rising to 11.4% in frequent exacerbators. Spirometry was recorded in only 3.5%, and eosinophil counts were missing in 41.6%. Vaccination coverage was suboptimal (influenza 51%, pneumococcal 16%, COVID-19 77%). Only 9.8% of patients received LABA + LAMA at the time of diagnosis, 30.7% received LABA + ICS and 32.4% had no registered long-acting inhaled therapy at all. Escalation to triple therapy after an exacerbation occurred in 27.7% of patients with exacerbations (218/786), with a median delay of 65 days. Separately, among all patients exposed to triple therapy at any time during follow-up (n = 492), 217 (44.1%) experienced ≥1 moderate exacerbation after triple therapy was initiated. COPD management in Flemish primary care shows major gaps in documentation, preventive care, and adherence to guideline-recommended pharmacological strategies. Delayed escalation and persistent exacerbations indicate system-level opportunities to improve diagnostic accuracy, optimize treatment, and strengthen preventive measures.