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Hakan Gunen,1 Nurdan Kokturk,2 Sibel Nayc&inodot;,3 Sevket Ozkaya,4 Birsen P&inodot;nar Y&inodot;ld&inodot;z,5 Onur Turan,6 Aziz Gumus,7 Metin Akgun,8 Alev Gurgun,9 Candan Ogus,10 Arzu Mirici,11 Elif Sen,12 Nazan Bayram,13 Volkan Eken,14 Hakan Erkus14 1Department of Pulmonary Medicine, Sureyyapasa Training and Research Centre for Chest Diseases and Thoracic Surgery, Istanbul, Turkey; 2Department of Pulmonary Medicine, Faculty of Medicine, Gazi University, Ankara, Turkey; 3Department of Pulmonary Medicine, Mersin University School of Medicine, Mersin, Turkey; 4Department of Pulmonary Medicine, VM Medical Park Samsun Hospital, Samsun, Turkey; 5University of Health Sciences, Yedikule Chest Disease and Surgery Training and Research Hospital, Pulmonology, Istanbul, Turkey; 6Department of Pulmonary Medicine, Izmir Katip Çelebi University, &Idot;zmir, Turkey; 7Department of Pulmonary Medicine, Recep Tayyip Erdogan University, Faculty of Medicine, Rize, Turkey; 8Department of Pulmonary Medicine, Atatürk University School of Medicine, Erzurum, Turkey; 9Department of Pulmonary Medicine, Ege University School of Medicine, &Idot;zmir, Turkey; 10Department of Pulmonary Medicine, Akdeniz University Medical Faculty, Antalya, Turkey; 11Department of Pulmonary Medicine, Canakkale 18 Mart University, Canakkale, Turkey; 12Department of Pulmonary Medicine, Ankara University School of Medicine, Ankara, Turkey; 13Department of Pulmonary Medicine, Gaziantep University, Sahinbey Research Hospital, Gaziantep, Turkey; 14GlaxoSmithKline, Istanbul, TurkeyCorrespondence: Hakan Gunen, Department of Pulmonary Medicine, Sureyyapasa Training and Research Centre for Chest Diseases and Thoracic Surgery, Istanbul, Turkey, Tel +90 532 621 16 99, Fax +90 216 421 41 10, Email hgunen@yahoo.com Nurdan Kokturk, Department of Pulmonary Medicine, Faculty of Medicine, Gazi University, Ankara, Turkey, Tel +90 532 627 91 11, Fax +90 312 212 90 19, Email nkokturk@gazi.edu.tr; kokturk.nurdan@gmail.comPurpose: GOLD 2019 proposed a novel treatment decision tool for follow-up based on the predominant trait (exacerbation or dyspnea) of patients, alongside treatment escalation and de-escalation strategies. This study was designed to provide an up-to-date snapshot of patient and disease characteristics, treatment pathways, and healthcare resource use (HRU) in COPD in real life, and comprehensively examine patients considering GOLD 2019 recommendations.Patients and Methods: This mixed design, observational, multicenter (14 pulmonology clinics) study included all patients with a documented COPD diagnosis (excluding asthma-COPD overlap [ACO]) for ≥ 12 months, aged ≥ 40 years at diagnosis who had a COPD-related hospital visit, spirometry test and blood eosinophil count (BEC) measurement under stable conditions within the 12 months before enrollment between February and December 2020. Data were collected cross-sectionally from patients and retrospectively from hospital medical records.Results: This study included 522 patients (GOLD group A: 17.2%, B: 46.4%, C: 3.3%, D: 33.1%), of whom 79.5% were highly symptomatic and 36.2% had high risk of exacerbation. Exacerbations (n = 832; 46.6% moderate, 25.5% severe) were experienced by 57.5% of patients in the previous 12 months. Inter-rater agreement between investigators and patients regarding the reason for visit was low (κ coefficient: 0.338, p = 0.001). Inhaled treatment was modified in 88 patients at index, mainly due to symptomatic state (31.8%) and exacerbations (27.3%); treatment was escalated (57.9%, mainly switched to LABA+LAMA+ICS), inhaler device and/or active ingredient was changed (36.4%) or treatment was de-escalated (5.7%). 27% had ≥ 1 hospital overnight stay over 12 months. Emergency department visits and days with limitation of daily activities were higher in group D (p < 0.001).Conclusion: Despite being on-treatment, many patients with COPD experience persistent symptoms and exacerbations requiring hospital-related HRU. A treatable trait approach and holistic disease management may improve outcomes by deciding the right treatment for the right patient at the right time.Keywords: COPD, GOLD, exacerbation, COPD treatment, eosinophilia