51
|
Kendzerska T, Zhu DT, Gershon AS, Edwards JD, Peixoto C, Robillard R, Kendall CE. The Effects of the Health System Response to the COVID-19 Pandemic on Chronic Disease Management: A Narrative Review. Risk Manag Healthc Policy 2021; 14:575-584. [PMID: 33623448 PMCID: PMC7894869 DOI: 10.2147/rmhp.s293471] [Citation(s) in RCA: 105] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 01/18/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Individuals with chronic conditions require ongoing disease management to reduce risks of adverse health outcomes. During the COVID-19 pandemic, health care for non-COVID-19 cases was affected due to the reallocation of resources towards urgent care for COVID-19 patients, resulting in inadequate ongoing care for chronic conditions. METHODS A keyword search was conducted in PubMed, Google Scholar, Science Direct, and Scopus for English language articles published between January 2020 and January 2021. FINDINGS During the COVID-19 pandemic, in-person care for individuals with chronic conditions have decreased due to government restriction of elective and non-urgent healthcare visits, greater instilled fear over potential COVID-19 exposure during in-person visits, and higher utilization rates of telemedicine compared to the pre-COVID-19 period. Potential benefits of a virtual-care framework during the pandemic include more effective routine disease monitoring, improved patient satisfaction, and increased treatment compliance and follow-up rates. However, more needs to be done to ensure timely and effective access to telemedicine, particularly for individuals with lower digital literacy. Capitation primary care models have been proposed as a more financially-robust approach during the COVID-19 pandemic than fee-for-service primary care models; however, the interplay between different primary models and the health outcomes is still poorly understood and warrants further investigation. Shortages of medication used to manage chronic conditions were also observed at the beginning of the COVID-19 pandemic due to global supply chain disruptions. Finally, patients with chronic conditions faced lifestyle disruptions due to the COVID-19 pandemic, specifically in physical activity, sleep, stress, and mental health, which need to be better addressed. INTERPRETATION Overall, this review elucidates the disproportionately greater barriers to primary and specialty care that patients with chronic diseases face during the COVID-19 pandemic and emphasizes the urgent need for better chronic disease management strategies moving forward.
Collapse
|
52
|
Gershon AS, Lindenauer PK, Wilson KC, Rose L, Walkey AJ, Sadatsafavi M, Anstrom KJ, Au DH, Bender BG, Brookhart MA, Dweik RA, Han MK, Joo MJ, Lavergne V, Mehta AB, Miravitlles M, Mularski RA, Roche N, Oren E, Riekert KA, Schoenberg NC, Stukel TA, Weiss CH, Wunsch H, Africk JJ, Krishnan JA. Informing Healthcare Decisions with Observational Research Assessing Causal Effect. An Official American Thoracic Society Research Statement. Am J Respir Crit Care Med 2021; 203:14-23. [PMID: 33385220 PMCID: PMC7781125 DOI: 10.1164/rccm.202010-3943st] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: Decisions in medicine are made on the basis of knowledge and reasoning, often in shared conversations with patients and families in consideration of clinical practice guideline recommendations, individual preferences, and individual goals. Observational studies can provide valuable knowledge to inform guidelines, decisions, and policy. Objectives: The American Thoracic Society (ATS) created a multidisciplinary ad hoc committee to develop a research statement to clarify the role of observational studies—alongside randomized controlled trials (RCTs)—in informing clinical decisions in pulmonary, critical care, and sleep medicine. Methods: The committee examined the strengths of observational studies assessing causal effects, how they complement RCTs, factors that impact observational study quality, perceptions of observational research, and, finally, the practicalities of incorporating observational research into ATS clinical practice guidelines. Measurements and Main Results: There are strengths and weakness of observational studies as well as RCTs. Observational studies can provide evidence in representative and diverse patient populations. Quality observational studies should be sought in the development of ATS clinical practice guidelines, and medical decision-making in general, when 1) no RCTs are identified or RCTs are appraised as being of low- or very low-quality (replacement); 2) RCTs are of moderate quality because of indirectness, imprecision, or inconsistency, and observational studies mitigate the reason that RCT evidence was downgraded (complementary); or 3) RCTs do not provide evidence for outcomes that a guideline committee considers essential for decision-making (e.g., rare or long-term outcomes; “sequential”). Conclusions: Observational studies should be considered in developing clinical practice guidelines and in making clinical decisions.
Collapse
|
53
|
Kendzerska T, Aaron SD, To T, Licskai C, Stanbrook MB, Hogan ME, Tan WC, Bourbeau J, Gershon AS. Effect of type and dosage of newly prescribed inhaled corticosteroids on obstructive lung disease and pneumonia hospitalisations in older individuals with asthma, COPD or both: a retrospective study of health administrative data. Eur Respir J 2021; 57:13993003.02585-2020. [PMID: 32703774 DOI: 10.1183/13993003.02585-2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 07/05/2020] [Indexed: 11/05/2022]
|
54
|
Cragg JJ, Azoulay L, Collins G, De Vera MA, Etminan M, Lalji F, Gershon AS, Guyatt G, Harrison M, Jutzeler C, Kassam R, Kendzerska T, Lynd L, Mansournia MA, Sadatsafavi M, Tong B, Warner FM, Tremlett H. The reporting of observational studies of drug effectiveness and safety: recommendations to extend existing guidelines. Expert Opin Drug Saf 2021; 20:1-8. [PMID: 33170749 DOI: 10.1080/14740338.2021.1849134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 11/06/2020] [Indexed: 12/17/2022]
Abstract
INTRODUCTION The use of observational data to assess drug effectiveness and safety can provide relevant information, much of which may not be feasible to obtain through randomized clinical trials. Because observational studies provide critical drug safety and effectiveness information that influences drug policy and prescribing practices, transparent, consistent, and accurate reporting of these studies is critical. AREAS COVERED We provide recommendations to extend existing reporting guidelines, covering the main components of primary research studies (methods, results, discussion). EXPERT OPINION Our recommendations include extending drug safety and effectiveness guidelines to include explicit checklist items on: study registration, causal diagrams, rationale for measures of effect, comprehensive assessment of bias, comprehensive data cleaning steps, drug equivalents, subject-level drug data visualization, sex and gender-based analyses and results, patient-oriented outcomes, and patient involvement in research.
Collapse
|
55
|
Wong AW, Lee TY, Johannson KA, Assayag D, Morisset J, Fell CD, Fisher JH, Shapera S, Gershon AS, Cox G, Halayko AJ, Hambly N, Manganas H, Sadatsafavi M, Wilcox PG, To T, Marcoux V, Khalil N, Kolb M, Ryerson CJ. A cluster-based analysis evaluating the impact of comorbidities in fibrotic interstitial lung disease. Respir Res 2020; 21:322. [PMID: 33287805 PMCID: PMC7720501 DOI: 10.1186/s12931-020-01579-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 11/19/2020] [Indexed: 02/07/2023] Open
Abstract
Background Comorbidities are frequent and have been associated with poor quality of life, increased hospitalizations, and mortality in patients with interstitial lung disease (ILD). However, it is unclear how comorbidities lead to these negative outcomes and whether they could influence ILD disease progression. The goal of this study was to identify clusters of patients based on similar comorbidity profiles and to determine whether these clusters were associated with rate of lung function decline and/or mortality. Methods Patients with a major fibrotic ILD (idiopathic pulmonary fibrosis (IPF), fibrotic hypersensitivity pneumonitis, connective tissue disease-associated ILD, and unclassifiable ILD) from the CAnadian REgistry for Pulmonary Fibrosis (CARE-PF) were included. Hierarchical agglomerative clustering of comorbidities, age, sex, and smoking pack-years was conducted for each ILD subtype to identify combinations of these features that frequently occurred together in patients. The association between clusters and change in lung function over time was determined using linear mixed effects modeling, with adjustment for age, sex, and smoking pack-years. Kaplan Meier curves were used to assess differences in survival between the clusters. Results Discrete clusters were identified within each fibrotic ILD. In IPF, males with obstructive sleep apnea (OSA) had more rapid decline in FVC %-predicted (− 11.9% per year [95% CI − 15.3, − 8.5]) compared to females without any comorbidities (− 8.1% per year [95% CI − 13.6, − 2.7]; p = 0.03). Females without comorbidities also had significantly longer survival compared to all other IPF clusters. There were no significant differences in rate of lung function decline or survival between clusters in the other fibrotic ILD subtypes. Conclusions The combination of male sex and OSA may portend worse outcomes in IPF. Further research is required to elucidate the interplay between sex and comorbidities in ILD, as well as the role of OSA in ILD disease progression.
Collapse
|
56
|
Kendzerska T, Povitz M, Leung RS, Boulos MI, McIsaac DI, Murray BJ, Bryson GL, Talarico R, Hilton JF, Malhotra A, Gershon AS. Obstructive Sleep Apnea and Incident Cancer: A Large Retrospective Multicenter Clinical Cohort Study. Cancer Epidemiol Biomarkers Prev 2020; 30:295-304. [PMID: 33268490 DOI: 10.1158/1055-9965.epi-20-0975] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 10/01/2020] [Accepted: 11/20/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND To examine the association between the severity of obstructive sleep apnea (OSA) and nocturnal hypoxemia with incident cancer. METHODS This was a multicenter retrospective clinical cohort study using linked clinical and provincial health administrative data on consecutive adults who underwent a diagnostic sleep study between 1994 and 2017 in four academic hospitals (Canada) who were free of cancer at baseline. Cancer status was derived from the Ontario Cancer Registry. Cox cause-specific regressions were utilized to address the objective and to calculate the 10-year absolute risk difference (ARD) in the marginal probability of incident cancer and the number needed to harm (NNH). RESULTS Of 33,997 individuals considered, 33,711 with no missing OSA severity were included: median age, 50 years; 58% male; and 23% with severe OSA (apnea-hypopnea index >30). Of the 18,458 individuals with information on sleep time spent with oxygen saturation (SaO2) <90%, 5% spent >30% of sleep with SaO2 <90% (severe nocturnal hypoxemia). Over a median of 7 years, 2,498 of 33,711 (7%) individuals developed cancer, with an incidence rate of 10.3 (10.0-10.8) per 1,000 person-years. Controlling for confounders, severe OSA was associated with a 15% increased hazard of developing cancer compared with no OSA (HR = 1.15, 1.02-1.30; ARD = 1.28%, 0.20-2.37; and NNH = 78). Severe hypoxemia was associated with about 30% increased hazard (HR = 1.32, 1.08-1.61; ARD = 2.38%, 0.47-4.31; and NNH = 42). CONCLUSIONS In a large cohort of individuals with suspected OSA free of cancer at baseline, the severity of OSA and nocturnal hypoxemia was independently associated with incident cancer. IMPACT These findings suggest the need for more targeted cancer risk awareness in individuals with OSA.
Collapse
|
57
|
Kouri A, Gupta S, Yadollahi A, Ryan CM, Gershon AS, To T, Tarlo SM, Goldstein RS, Chapman KR, Chow CW. Addressing Reduced Laboratory-Based Pulmonary Function Testing During a Pandemic. Chest 2020; 158:2502-2510. [PMID: 32652095 PMCID: PMC7345485 DOI: 10.1016/j.chest.2020.06.065] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 06/23/2020] [Accepted: 06/27/2020] [Indexed: 01/04/2023] Open
Abstract
To reduce the spread of the severe acute respiratory syndrome coronavirus 2, many pulmonary function testing (PFT) laboratories have been closed or have significantly reduced their testing capacity. Because these mitigation strategies may be necessary for the next 6 to 18 months to prevent recurrent peaks in disease prevalence, fewer objective measurements of lung function will alter the diagnosis and care of patients with chronic respiratory diseases. PFT, which includes spirometry, lung volume, and diffusion capacity measurement, is essential to the diagnosis and management of patients with asthma, COPD, and other chronic lung conditions. Both traditional and innovative alternatives to conventional testing must now be explored. These may include peak expiratory flow devices, electronic portable spirometers, portable exhaled nitric oxide measurement, airwave oscillometry devices, and novel digital health tools such as smartphone microphone spirometers and mobile health technologies along with integration of machine learning approaches. The adoption of some novel approaches may not merely replace but could improve existing management strategies and alter common diagnostic paradigms. With these options comes important technical, privacy, ethical, financial, and medicolegal barriers that must be addressed. However, the coronavirus disease 19 pandemic also presents a unique opportunity to augment conventional testing by including innovative and emerging approaches to measuring lung function remotely in patients with respiratory disease. The benefits of such an approach have the potential to enhance respiratory care and empower patient self-management well beyond the current global pandemic.
Collapse
|
58
|
Lee TMH, Tobe SW, Butt DA, Ivers NM, Gershon AS, Barnsley J, Liu PP, Jaakkimainen L, Walker KM, Tu K. Patient- and Physician-Level Factors Associated With Adherence to C-CHANGE Recommendations in Primary Care Settings in Ontario. CJC Open 2020; 2:563-576. [PMID: 33305217 PMCID: PMC7711016 DOI: 10.1016/j.cjco.2020.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 07/11/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND We previously found large variation among family physicians in adherence to the Canadian Cardiovascular Harmonization of National Guidelines Endeavour (C-CHANGE). We assessed the role of patient- and physician-level factors in the variation in adherence to recommendations for managing cardiovascular disease risk factors. METHODS We conducted a retrospective study using multilevel logistic regression analyses with the Electronic Medical Record Administrative data Linked Database (EMRALD) housed at ICES in Ontario. Five quality indicators based on C-CHANGE guidelines were modelled. Effects of clustering and between-group variation, patient-level (sociodemographics, comorbidities) and physician-level characteristics (demographic and practice information) were assessed to determine odds ratios of receiving C-CHANGE recommended care. RESULTS In all, 324 Ontario physicians practicing in 41 clinics who provided care to 227,999 adult patients were studied. We found significant variation in quality indicators, with 15% to 39% of the total variation attributable to nonpatient factors. The largest variation was in performing 2-hour plasma glucose testing in prediabetic patients. Patient-level factors most frequently associated with recommendation adherence included sex, age, and multi-comorbidities. Women were more likely than men to have their body mass index measured, and their blood pressure controlled, but less likely to receive antiplatelet medications and liver-enzyme testing if overweight or obese. CONCLUSIONS The majority of variations in adherence were attributable to patient attributes, but a substantial proportion of unexplained variation was due to differences among physicians and clinics. This finding may signal suboptimal processes or structures and warrant further investigation to improve the quality of primary care management of cardiovascular disease in Ontario.
Collapse
|
59
|
Tsai APY, Hur SA, Wong A, Safavi M, Assayag D, Johannson KA, Morisset J, Fell C, Fisher JH, Manganas H, Shapera S, Cox G, Gershon AS, Hambly N, Khalil N, To T, Wilcox PG, Halayko A, Kolb MR, Ryerson CJ. Minimum important difference of the EQ-5D-5L and EQ-VAS in fibrotic interstitial lung disease. Thorax 2020; 76:37-43. [PMID: 33023996 DOI: 10.1136/thoraxjnl-2020-214944] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 08/28/2020] [Accepted: 09/02/2020] [Indexed: 11/04/2022]
Abstract
RATIONALE The European Quality of Life 5-Dimensions 5-Levels questionnaire (EQ-5D-5L) is a multidimensional patient-reported questionnaire that supports calculation of quality-adjusted life-years. Our objectives were to demonstrate feasibility of use and to calculate the minimum important difference (MID) of the EQ-5D-5L and its associated visual analogue scale (EQ-VAS) in patients with fibrotic interstitial lung disease (ILD). METHODS Patients who completed the EQ-5D-5L were identified from the prospective multicentre CAnadian REgistry for Pulmonary Fibrosis. Validity, internal consistency and responsiveness of the EQ-5D-5L were assessed, followed by calculation of the MID for the EQ-5D-5L and EQ-VAS. Anchor-based methods used an unadjusted linear regression against pulmonary function tests (PFTs) and dyspnoea and other quality of life questionnaires. Distribution-based method used one-half SD and SE measurement (SEM) calculations. RESULTS 1816 patients were analysed, including 472 (26%) with idiopathic pulmonary fibrosis. EQ-5D-5L scores were strongly correlated with the dyspnoea and other quality of life questionnaires and weakly associated with PFTs. The estimated MID for EQ-5D-5L ranged from 0.0050 to 0.054 and from 0.078 to 0.095 for the anchor-based and distribution-based methods, respectively. The MID for EQ-VAS ranged from 0.5 to 5.0 and from 8.0 to 9.7 for the anchor-based and distribution-based methods. Findings were similar across ILD subtypes, sex and age. CONCLUSION We used a large and diverse cohort of patients with a variety of fibrotic ILD subtypes to suggest validity and MID of both the EQ-5D-5L and EQ-VAS. These findings will assist in designing future clinical trials and supporting cost-effectiveness analyses of potential treatments for patients with fibrotic ILD.
Collapse
|
60
|
Gershon AS, McGihon RE, Thiruchelvam D, To T, Wu R, Bell CM, Aaron SD. Medication Discontinuation in Adults With COPD Discharged From the Hospital: A Population-Based Cohort Study. Chest 2020; 159:975-984. [PMID: 33011204 DOI: 10.1016/j.chest.2020.09.254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 09/21/2020] [Accepted: 09/25/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Patients admitted to the hospital with COPD are commonly managed with inhaled short-acting bronchodilators, sometimes in lieu of the long-acting bronchodilators they take as outpatients. If held on admission, these long-acting inhalers should be re-initiated upon discharge; however, health-care transitions sometimes result in unintentional discontinuation. RESEARCH QUESTION What is the risk of unintentional discontinuation of long-acting muscarinic antagonist (LAMA) and long-acting beta-agonist and inhaled corticosteroid (LABA-ICS) combination medications following hospital discharge in older adults with COPD? STUDY DESIGN AND METHODS A retrospective cohort study was conducted by using health administrative data from 2004 to 2016 from Ontario, Canada. Adults with COPD aged ≥ 66 years who had filled prescriptions for a LAMA or LABA-ICS continuously for ≥ 1 year were included. Log-binomial regression models were used to determine risk of medication discontinuation following hospitalization in each medication cohort. RESULTS Of the 27,613 hospitalization discharges included in this study, medications were discontinued 1,466 times. Among 78,953 patients with COPD continuously taking a LAMA or LABA-ICS, those hospitalized had a higher risk of having medications being discontinued than those who remained in the community (adjusted risk ratios of 1.50 [95% CI, 1.34-1.67; P < .001] and 1.62 [95% CI, 1.39, 1.90; P < .001] for LAMA and LABA-ICS, respectively). Crude rates of discontinuation for people taking LAMAs were 5.2% in the hospitalization group and 3.3% in the community group; for people taking LABA-ICS, these rates were 5.5% in the hospitalization group and 3.1% in the community group. INTERPRETATION In an observational study of highly compliant patients with COPD, hospitalization was associated with an increased risk of long-acting inhaler discontinuation. These Results suggest a likely larger discontinuation problem among less adherent patients and should be confirmed and quantified in a prospective cohort of patients with COPD and average compliance. Quality improvement efforts should focus on safe transitions and patient medication reconciliation following discharge.
Collapse
|
61
|
Vozoris NT, Pequeno P, Li P, Austin PC, Stephenson AL, O'Donnell DE, Gill SS, Gershon AS, Rochon PA. Morbidity and mortality associated with prescription cannabinoid drug use in COPD. Thorax 2020; 76:29-36. [DOI: 10.1136/thoraxjnl-2020-215346] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/11/2020] [Accepted: 08/25/2020] [Indexed: 01/18/2023]
Abstract
IntroductionRespiratory-related morbidity and mortality were evaluated in relation to incident prescription oral synthetic cannabinoid (nabilone, dronabinol) use among older adults with chronic obstructive pulmonary disease (COPD).MethodsThis was a retrospective, population-based, data-linkage cohort study, analysing health administrative data from Ontario, Canada, from 2006 to 2016. We identified individuals aged 66 years and older with COPD, using a highly specific, validated algorithm, excluding individuals with malignancy and those receiving palliative care (n=185 876 after exclusions). An equivalent number (2106 in each group) of new cannabinoid users (defined as individuals dispensed either nabilone or dronabinol, with no dispensing for either drug in the year previous) and controls (defined as new users of a non-cannabinoid drug) were matched on 36 relevant covariates, using propensity scoring methods. Cox proportional hazard regression was used.ResultsRate of hospitalisation for COPD or pneumonia was not significantly different between new cannabinoid users and controls (HR 0.87; 95% CI 0.61–1.24). However, significantly higher rates of all-cause mortality occurred among new cannabinoid users compared with controls (HR 1.64; 95% CI 1.14–2.39). Individuals receiving higher-dose cannabinoids relative to controls were observed to experience both increased rates of hospitalisation for COPD and pneumonia (HR 2.78; 95% CI 1.17–7.09) and all-cause mortality (HR 3.31; 95% CI 1.30–9.51).ConclusionsNew cannabinoid use was associated with elevated rates of adverse outcomes among older adults with COPD. Although further research is needed to confirm these observations, our findings should be considered in decisions to use cannabinoids among older adults with COPD.
Collapse
|
62
|
Butler SJ, Ellerton L, Gershon AS, Goldstein RS, Brooks D. Comparison of end-of-life care in people with chronic obstructive pulmonary disease or lung cancer: A systematic review. Palliat Med 2020; 34:1030-1043. [PMID: 32484762 DOI: 10.1177/0269216320929556] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Palliative care has been widely implemented in clinical practice for patients with cancer but is not routinely provided to people with chronic obstructive pulmonary disease. AIM The study aims were to compare palliative care services, medications, life-sustaining interventions, place of death, symptom burden and health-related quality of life among chronic obstructive pulmonary disease and lung cancer populations. DESIGN Systematic review with meta-analysis (PROSPERO: CRD42019139425). DATA SOURCES MEDLINE, EMBASE, PubMed, CINAHL and PsycINFO were searched for studies comparing palliative care, symptom burden or health-related quality of life among chronic obstructive pulmonary disease, lung cancer or populations with both conditions. Quality scores were assigned using the QualSyst tool. RESULTS Nineteen studies were included. There was significant heterogeneity in study design and sample size. A random effects meta-analysis (n = 3-7) determined that people with lung cancer had higher odds of receiving hospital (odds ratio: 9.95, 95% confidence interval: 6.37-15.55, p < 0.001) or home-based palliative care (8.79, 6.76-11.43, p < 0.001), opioids (4.76, 1.87-12.11, p = 0.001), sedatives (2.03, 1.78-2.32, p < 0.001) and dying at home (1.47, 1.14-1.89, p = 0.003) compared to people with chronic obstructive pulmonary disease. People with lung cancer had lower odds of receiving invasive ventilation (0.26, 0.22-0.32, p < 0.001), non-invasive ventilation (0.63, 0.44-0.89, p = 0.009), cardiopulmonary resuscitation (0.29, 0.18-0.47, p < 0.001) or dying at a nursing home/long-term care facility (0.32, 0.16-0.64, p < 0.001) than people with chronic obstructive pulmonary disease. Symptom burden and health-related quality of life were relatively similar between the two populations. CONCLUSION People with chronic obstructive pulmonary disease receive less palliative measures at the end of life compared to people with lung cancer, despite a relatively similar symptom profile.
Collapse
|
63
|
Nici L, Mammen MJ, Charbek E, Alexander PE, Au DH, Boyd CM, Criner GJ, Donaldson GC, Dreher M, Fan VS, Gershon AS, Han MK, Krishnan JA, Martinez FJ, Meek PM, Morgan M, Polkey MI, Puhan MA, Sadatsafavi M, Sin DD, Washko GR, Wedzicha JA, Aaron SD. Pharmacologic Management of Chronic Obstructive Pulmonary Disease. An Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med 2020; 201:e56-e69. [PMID: 32283960 PMCID: PMC7193862 DOI: 10.1164/rccm.202003-0625st] [Citation(s) in RCA: 185] [Impact Index Per Article: 46.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background: This document provides clinical recommendations for the pharmacologic treatment of chronic obstructive pulmonary disease (COPD). It represents a collaborative effort on the part of a panel of expert COPD clinicians and researchers along with a team of methodologists under the guidance of the American Thoracic Society. Methods: Comprehensive evidence syntheses were performed on all relevant studies that addressed the clinical questions and critical patient-centered outcomes agreed upon by the panel of experts. The evidence was appraised, rated, and graded, and recommendations were formulated using the Grading of Recommendations, Assessment, Development, and Evaluation approach. Results: After weighing the quality of evidence and balancing the desirable and undesirable effects, the guideline panel made the following recommendations: 1) a strong recommendation for the use of long-acting β2-agonist (LABA)/long-acting muscarinic antagonist (LAMA) combination therapy over LABA or LAMA monotherapy in patients with COPD and dyspnea or exercise intolerance; 2) a conditional recommendation for the use of triple therapy with inhaled corticosteroids (ICS)/LABA/LAMA over dual therapy with LABA/LAMA in patients with COPD and dyspnea or exercise intolerance who have experienced one or more exacerbations in the past year; 3) a conditional recommendation for ICS withdrawal for patients with COPD receiving triple therapy (ICS/LABA/LAMA) if the patient has had no exacerbations in the past year; 4) no recommendation for or against ICS as an additive therapy to long-acting bronchodilators in patients with COPD and blood eosinophilia, except for those patients with a history of one or more exacerbations in the past year requiring antibiotics or oral steroids or hospitalization, for whom ICS is conditionally recommended as an additive therapy; 5) a conditional recommendation against the use of maintenance oral corticosteroids in patients with COPD and a history of severe and frequent exacerbations; and 6) a conditional recommendation for opioid-based therapy in patients with COPD who experience advanced refractory dyspnea despite otherwise optimal therapy. Conclusions: The task force made recommendations regarding the pharmacologic treatment of COPD based on currently available evidence. Additional research in populations that are underrepresented in clinical trials is needed, including studies in patients with COPD 80 years of age and older, those with multiple chronic health conditions, and those with a codiagnosis of COPD and asthma.
Collapse
|
64
|
Gershon AS, Chung H, Porter J, Campitelli MA, Buchan SA, Schwartz KL, Crowcroft NS, Campigotto A, Gubbay JB, Karnauchow T, Katz K, McGeer AJ, McNally JD, Richardson DC, Richardson SE, Rosella LC, Simor AE, Smieja M, Zahariadis G, Kwong JC. Influenza Vaccine Effectiveness in Preventing Hospitalizations in Older Patients With Chronic Obstructive Pulmonary Disease. J Infect Dis 2020; 221:42-52. [PMID: 31549165 DOI: 10.1093/infdis/jiz419] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 08/30/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Annual influenza immunization is recommended for people with chronic obstructive pulmonary disease (COPD) by all major COPD clinical practice guidelines. We sought to determine the seasonal influenza vaccine effectiveness (VE) against laboratory-confirmed influenza-associated hospitalizations among older adults with COPD. METHODS We conducted a test-negative study of influenza VE in community-dwelling older adults with COPD in Ontario, Canada using health administrative data and respiratory specimens collected from patients tested for influenza during the 2010-11 to 2015-16 influenza seasons. Influenza vaccination was ascertained from physician and pharmacist billing claims. Multivariable logistic regression was used to estimate the adjusted odds ratio of influenza vaccination in people with, compared to those without, laboratory-confirmed influenza. RESULTS Receipt of seasonal influenza vaccine was associated with an adjusted 22% (95% confidence interval [CI], 15%-27%) reduction in laboratory-confirmed influenza-associated hospitalization. Adjustment for potential misclassification of vaccination status increased this to 43% (95% CI, 35%-52%). Vaccine effectiveness was not found to vary by patient- or influenza-related variables. CONCLUSIONS During the studied influenza seasons, influenza vaccination was at least modestly effective in reducing laboratory-confirmed influenza-associated hospitalizations in people with COPD. The imperfect effectiveness emphasizes the need for better influenza vaccines and other preventive strategies.
Collapse
|
65
|
Sankar A, Thorpe KE, Gershon AS, Granton JT, Wijeysundera DN. Association of preoperative spirometry with cardiopulmonary fitness and postoperative outcomes in surgical patients: A multicentre prospective cohort study. EClinicalMedicine 2020; 23:100396. [PMID: 32529180 PMCID: PMC7280772 DOI: 10.1016/j.eclinm.2020.100396] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Preoperative spirometry and cardiopulmonary exercise testing (CPET) may stratify risk for respiratory complications. This secondary analysis of the Measurement of Exercise Tolerance before Surgery (METS) study examined whether CPET performance (i.e., cardiopulmonary fitness) confounds associations of spirometry with outcomes. METHODS The analysis included 1200 participants having major non-cardiac surgery at 25 hospitals in Canada, Australia, New Zealand and UK. Forced expiratory volume in 1 s (FEV1), and ratio of FEV1 to forced vital capacity (FVC) were measured during preoperative spirometry, and peak oxygen consumption and ventilatory efficiency during preoperative CPET. Outcomes were respiratory morbidity (Postoperative Morbidity Survey) and pulmonary complications (pneumonia or respiratory failure). We used multivariable logistic regression models to estimate associations of FEV1 with outcomes after adjustment for risk factors and either peak oxygen consumption or ventilatory efficiency. FINDINGS 128 participants (11%) developed respiratory morbidity, and 48 (4%) developed pulmonary complications. There was no strong evidence that FEV1 predicted respiratory morbidity after adjustment for peak oxygen consumption (p = 0·80) or ventilatory efficiency (p = 0·76), or FEV1 predicted pulmonary complications after adjustment for ventilatory efficiency (p = 0·37). Peak oxygen consumption (odds ratio 0·66 per 5 mL/kg/min increase; 95% CI, 0·54-0·82) was associated with respiratory morbidity. Ventilatory efficiency was associated with respiratory morbidity (p = 0·04) and pulmonary complications (p = 0·02). Peak oxygen consumption also confounded the association between FEV1 and respiratory morbidity. INTERPRETATION After accounting for fitness and clinical factors, FEV1 was not strongly predictive of respiratory complications. Prior associations between FEV1 and respiratory morbidity may be explained by confounding by peak oxygen consumption. FUNDING Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Ontario Ministry of Health and Long-Term Care, Ontario Ministry of Research, Innovation and Science, UK National Institute of Academic Anaesthesia, UK Clinical Research Collaboration, Australian and New Zealand College of Anaesthetists, and Monash University.
Collapse
|
66
|
Press VG, Gershon AS, Sciurba FC, Blagev DP. Concerns About Coronavirus Disease-Related Collateral Damage for Patients With COPD. Chest 2020; 158:866-868. [PMID: 32473947 PMCID: PMC7837125 DOI: 10.1016/j.chest.2020.05.549] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 05/18/2020] [Accepted: 05/20/2020] [Indexed: 12/01/2022] Open
|
67
|
Marras C, Pequeno P, Austin PC, Gershon AS, Iqbal J, Rochon PA, Lang AE. Beta Agonists and Progression of Parkinson's Disease in Older Adults: A Retrospective Cohort Study. Mov Disord 2020; 35:1275-1277. [PMID: 32412138 DOI: 10.1002/mds.28085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 03/12/2020] [Accepted: 04/13/2020] [Indexed: 11/10/2022] Open
|
68
|
Antoniou T, Yao Z, Raboud J, Gershon AS. Incidence of chronic obstructive pulmonary disease in people with HIV in Ontario, 1996-2015: a retrospective population-based cohort study. CMAJ Open 2020; 8:E83-E89. [PMID: 32071142 PMCID: PMC7028164 DOI: 10.9778/cmajo.20190028] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Because of high smoking rates and HIV-related factors, people with HIV may be at high risk for chronic obstructive pulmonary disease (COPD); however, population-based estimates of the incidence of COPD among people with HIV are lacking, particularly for women. We compared the incidence of COPD among Ontario adults aged 35 years or more with and without HIV between Jan. 1, 1996, and Dec. 31, 2015. METHODS We conducted a population-based study using Ontario's health administrative databases. We compared the incidence of COPD between people with and without HIV using standardized incidence ratios and generalized estimating equations with a log link function. RESULTS We identified 1849 people with HIV and 1 168 727 HIV-negative people who were newly diagnosed with COPD between 1996 and 2015. People with HIV were younger than HIV-negative people (mean age 49.7 [standard deviation 10.4] yr v. 62.2 [standard deviation 14.8] yr; standardized difference 0.98). Rates of COPD were higher among people with HIV than among HIV-negative people (10.4 v. 9.0 cases per 1000 person-years; standardized incidence ratio 1.16, 95% confidence interval [CI] 1.10 to 1.21; adjusted rate ratio 1.34, 95% CI 1.27 to 1.41). In sex-stratified analyses, rates of COPD were higher among men with HIV (adjusted rate ratio 1.32, 95% CI 1.24 to 1.40) and women with HIV (adjusted rate ratio 1.54, 95% CI 1.37 to 1.72) than among men and women without HIV. In a sensitivity analysis, smoking explained observed differences in COPD incidence. INTERPRETATION People with HIV had higher rates of incident COPD than HIV-negative people. This may reflect the disproportionately higher prevalence of smoking among the former.
Collapse
|
69
|
Butler SJ, Li LSK, Ellerton L, Gershon AS, Goldstein RS, Brooks D. Prevalence of comorbidities and impact on pulmonary rehabilitation outcomes. ERJ Open Res 2019; 5:00264-2019. [PMID: 31832430 PMCID: PMC6899339 DOI: 10.1183/23120541.00264-2019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 10/07/2019] [Indexed: 01/11/2023] Open
Abstract
Background The presence of comorbid conditions could impact performance in pulmonary rehabilitation (PR) programmes. We aimed to compare the comorbidity prevalence among those with chronic obstructive pulmonary disease (COPD) and interstitial lung disease (ILD) and evaluate the impact on PR response. Methods We performed a retrospective cohort study, recording comorbidities for all patients with COPD or ILD referred to PR. Participants were classified as responders to PR if they met the minimal important difference for exercise capacity and health-related quality of life (HRQoL). The prevalence of comorbidities and impact on PR outcomes were compared by lung disease and by sex using a univariate analysis and multivariate logistic regression. Results The mean number of comorbidities was similar among those with COPD (3.3±2.1, n=242) and ILD (3.2±1.9, n=66) (p>0.05). Females had a higher number of comorbidities than males in both COPD (p=0.001) and ILD (p=0.017) populations. Circulatory (64%) and endocrine/metabolic (45%) conditions were most common in COPD. In ILD, digestive (55%) and circulatory (53%) comorbidities were most prevalent. In people with ILD, those over 65 years, with musculoskeletal/connective tissue disease or circulatory disease were less likely to obtain meaningful improvements in exercise capacity. There was no impact of comorbidities on exercise capacity in COPD or on HRQoL in ILD. Conclusions The majority of patients with COPD or ILD enrolled in PR programmes have multiple comorbidities that may affect improvements in exercise capacity. PR programmes may be less effective for older adults with ILD and comorbid circulatory or musculoskeletal disease.
Collapse
|
70
|
Fisher JH, Kolb M, Algamdi M, Morisset J, Johannson KA, Shapera S, Wilcox P, To T, Sadatsafavi M, Manganas H, Khalil N, Hambly N, Halayko AJ, Gershon AS, Fell CD, Cox G, Ryerson CJ. Baseline characteristics and comorbidities in the CAnadian REgistry for Pulmonary Fibrosis. BMC Pulm Med 2019; 19:223. [PMID: 31771541 PMCID: PMC6880596 DOI: 10.1186/s12890-019-0986-4] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 11/08/2019] [Indexed: 12/02/2022] Open
Abstract
Background The CAnadian REgistry for Pulmonary Fibrosis (CARE-PF) is a multi-center, prospective registry designed to study the natural history of fibrotic interstitial lung disease (ILD) in adults. The aim of this cross-sectional sub-study was to describe the baseline characteristics, risk factors, and comorbidities of patients enrolled in CARE-PF to date. Methods Patients completed study questionnaires and clinical measurements at enrollment and each follow-up visit. Environmental exposures were assessed by patient self-report and comorbidities by the Charlson Comorbidity Index (CCI). Baseline characteristics, exposures, and comorbidities were described for the overall study population and for incident cases, and were compared across ILD subtypes. Results The full cohort included 1285 patients with ILD (961 incident cases (74.8%)). Diagnoses included connective tissue disease-associated ILD (33.3%), idiopathic pulmonary fibrosis (IPF) (24.7%), unclassifiable ILD (22.3%), chronic hypersensitivity pneumonitis (HP) (7.5%), sarcoidosis (3.2%), non-IPF idiopathic interstitial pneumonias (3.0%, including idiopathic nonspecific interstitial pneumonia (NSIP) in 0.9%), and other ILDs (6.0%). Patient-reported exposures were most frequent amongst chronic HP, but common across all ILD subtypes. The CCI was ≤2 in 81% of patients, with a narrow distribution and range of values. Conclusions CTD-ILD, IPF, and unclassifiable ILD made up 80% of ILD diagnoses at ILD referral centers in Canada, while idiopathic NSIP was rare when adhering to recommended diagnostic criteria. CCI had a very narrow distribution across our cohort suggesting it may be a poor discriminator in assessing the impact of comorbidities on patients with ILD.
Collapse
|
71
|
Patel MR, Press VG, Gerald LB, Barnes T, Blake K, Brown LK, Costello RW, Crim C, Forshag M, Gershon AS, Goss CH, Han MK, Lee TA, Sweet S, Gerald JK. Improving the Affordability of Prescription Medications for People with Chronic Respiratory Disease. An Official American Thoracic Society Policy Statement. Am J Respir Crit Care Med 2019; 198:1367-1374. [PMID: 30601674 DOI: 10.1164/rccm.201810-1865st] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Mounting evidence indicates that out-of-pocket costs for prescription medications, particularly among low- and middle-income patients with chronic diseases, are imposing financial burden, reducing medication adherence, and worsening health outcomes. This problem is exacerbated by a paucity of generic alternatives for prevalent lung diseases, such as asthma and chronic obstructive pulmonary disease, as well as high-cost medicines for rare diseases, such as cystic fibrosis. Affordability and access challenges are especially salient in the United States, as citizens of many other countries pay lower prices for and have greater access to prescription medications. METHODS The American Thoracic Society convened a multidisciplinary committee comprising experts in health policy pharmacoeconomics, behavioral sciences, and clinical care, along with individuals providing industry and patient perspectives. The report and its recommendation were iteratively developed over a year of in-person, telephonic, and electronic deliberation. RESULTS The committee unanimously recommended the establishment of a publicly funded, politically independent, impartial entity to systematically draft evidence-based pharmaceutical policy recommendations. The goal of this entity would be to generate evidence and action steps to ensure people have equitable and affordable access to prescription medications, to maximize the value of public and private pharmaceutical expenditures on health, to support novel drug development within a market-based economy, and to preserve clinician and patient choice regarding personalized treatment. An immediate priority is to examine the evidence and make recommendations regarding the need to have essential medicines with established clinical benefit from each drug class in all Tier 1 formularies and propose recommendations to reduce barriers to timely generic drug availability. CONCLUSIONS By making explicit, evidence-based recommendations, the entity can support the establishment of coherent national policies that expand access to affordable medications, improve the health of patients with chronic disease, and optimize the use of public and private resources.
Collapse
|
72
|
Gershon AS, Maclagan LC, Luo J, To T, Kendzerska T, Stanbrook MB, Bourbeau J, Etches J, Aaron SD. End-of-Life Strategies among Patients with Advanced Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2019; 198:1389-1396. [PMID: 29889548 DOI: 10.1164/rccm.201803-0592oc] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
RATIONALE The burden of advanced chronic obstructive pulmonary disease (COPD) is high globally; however, little is known about how often end-of-life strategies are used by this population. OBJECTIVES To describe trends in the use of end-of-life care strategies by people with advanced COPD in Ontario, Canada. METHODS A population-based repeated cross-sectional study examining end-of-life care strategies in individuals with advanced COPD was conducted. Annual proportions of individuals who received formal palliative care, long-term oxygen therapy, or opioids from 2004 to 2014 were determined. Results were age and sex standardized and stratified by age, sex, socioeconomic status, urban/rural residence, and immigrant status. Measurement/Main Results: There were 151,912 persons with advanced COPD in Ontario between 2004 and 2014. Use of formal palliative care services increased 1% per year from 5.3% in 2004 to 14.3% in 2014 (P value for trend < 0.001), whereas use of long-term oxygen therapy increased 1.1% per year from 26.4% in 2004 to 35.3% in 2013 (P value for trend < 0.001). The use of opioids was relatively stable (40.0% in 2004 and 41.8% in 2014; P value for trend = 0.08). Younger individuals were less likely to use formal palliative care services and long-term oxygen therapy. Males were less likely than females to receive long-term oxygen therapy and opioids. CONCLUSIONS The proportion of people with advanced COPD using end-of-life strategies, although increasing, remains low. Efforts should focus on increasing access to such strategies and educating patients and providers of their benefits.
Collapse
|
73
|
Wu RC, Ginsburg S, Son T, Gershon AS. Using wearables and self-management apps in patients with COPD: a qualitative study. ERJ Open Res 2019; 5:00036-2019. [PMID: 31528634 PMCID: PMC6734006 DOI: 10.1183/23120541.00036-2019] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 06/11/2019] [Indexed: 11/22/2022] Open
Abstract
Background Technology such as wearable technology and self-management applications could improve the care of patients with chronic obstructive pulmonary disease (COPD) by real-time continuous monitoring, early detection of COPD and improved self-management. However, patients have not been willing to use technology when it is too difficult to use, interferes with their daily lives or threatens their identity, independence and self-care. Methods We conducted a qualitative study to determine what patients with COPD would like to see in a wearable device and a mobile application to help manage their condition. Semi-structured interviews were conducted, recorded and transcribed. Thematic analysis was used to identify themes and concepts. Results We interviewed 14 people with COPD with an average age of 69 years. Participants perceived that the technology could improve their ability to manage their condition both in daily life and during exacerbations by connecting how they feel and by knowing their oxygen saturation, heart rate and activity. The technology may help them address feelings of fear and panic associated with exacerbations and may provide reassurance and connectedness. Some people with COPD wanted their healthcare providers to have access to their data, while others were concerned about inundating them with too much information. Of note, people wanted to maintain control of the information; to make connections with the data, but also in order to be alerted when a possible exacerbation occurs. Conclusion Patients perceived significant potential for wearables and apps to help manage their condition. In-depth interviews with COPD patients found that they face significant challenges managing their condition. Patients perceive significant potential for wearables to help with self-management and alerting them to a possible exacerbation.http://bit.ly/2xcyBlB
Collapse
|
74
|
Tavakoli H, Johnson KM, FitzGerald JM, Sin DD, Gershon AS, Kendzerska T, Sadatsafavi M. Trends in prescriptions and costs of inhaled medications in chronic obstructive pulmonary disease: a 19-year population-based study from Canada. Int J Chron Obstruct Pulmon Dis 2019; 14:2003-2013. [PMID: 31564848 PMCID: PMC6732655 DOI: 10.2147/copd.s210897] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 08/15/2019] [Indexed: 11/30/2022] Open
Abstract
Background The patterns of medication use in chronic obstructive pulmonary disease (COPD) may change over time due to the availability of new medications, updates in guideline-based recommendations, and changes in patient and care provider preferences. Objectives To document population-level trends of filled prescriptions and costs for major classes of inhaled COPD therapies. Method We used administrative health databases of the province of British Columbia, Canada, from 1997 to 2015, to create a retrospective cohort of COPD patients. We documented the percentage of patients receiving major inhaled COPD-related medications, including short-acting beta-2 adrenoreceptor agonists (SABA), long-acting beta-2 adrenoreceptor agonists (LABA), inhaled corticosteroids (ICS), short-acting muscarinic receptor antagonists (SAMA), and long-acting muscarinic receptor antagonists (LAMA). We quantified the average, and relative annual change in, dispensed quantities and costs (in 2015 Canadian dollars [$]) of medications. Combination therapy was assessed as the proportion of time covered by two or more long-acting medications of different classes. Results A total of 176,338 patients were included in the final cohort (mean age at entry 68.7, 48.5% female). In 2015, the most common medication was ICS (45.7% of the patients), followed by LABA (36.5%). LAMA was the least used medication (18.9%). The number of filled prescriptions per patient per year for LAMA (+7.8% per year) and LABA (+4.9%) increased, while they decreased for SAMA (−6.3%) and SABA (−3.8%), and remained relatively constant for ICS. The average annual per-patient costs of inhaled medications were $570.8 in 2015, which was double the costs from 1997. Single-inhaler ICS/LABA had the highest rate of increase (11.6% per year), and comprised 53.7% of the total costs of inhalers in 2015. In 2015, 28.5% of the patient time was on combination therapies, with 7.1% on triple ICS/LABA/LAMA therapy. Conclusion Utilization of inhaled therapies for COPD has changed significantly over time. The low utilization of LAMA and high utilization of combination therapies (particularly those containing ICS) do not seem to be aligned with COPD treatment guidelines.
Collapse
|
75
|
Chen W, Subbarao P, McGihon RE, Feldman LY, Zhu J, Lou W, Gershon AS, Abdullah K, Moraes TJ, Dubeau A, Sears MR, Lefebvre DL, Turvey SE, Mandhane PJ, Azad MB, To T. Patterns of health care use related to respiratory conditions in early life: A birth cohort study with linked administrative data. Pediatr Pulmonol 2019; 54:1267-1276. [PMID: 31172683 DOI: 10.1002/ppul.24381] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 05/03/2019] [Accepted: 05/09/2019] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To identify distinctive patterns of respiratory-related health services use (HSU) between birth and 3 years of age, and to examine associated symptom and risk profiles. METHODS This study included 729 mother and child pairs enrolled in the Toronto site of the Canadian Healthy Infant Longitudinal Development study in 2009-2012; they were linked to Ontario health administrative databases (2009-2016). A model-based cluster analysis was performed to identify distinct groups of children who followed a similar pattern of respiratory-related HSU between birth and 3 years of age, regarding hospitalization, emergency department (ED) and physician office visits for respiratory conditions and total health care costs (2016 Canadian dollars). RESULTS The majority (estimated cluster weight = 0.905) showed a pattern of low and stable respiratory care use (low HSU) while the remainder (weight = 0.095) showed a pattern of high use (high HSU). From 0 to 3 years of age, the low- and high-HSU groups differed in mean trajectories of total health care costs ($783 per 6 months decreased to $114, vs $1796 to $177, respectively). Compared to low-HSU, the high-HSU group was associated with a constant risk of hospitalizations, early high ED utilization and physician visits for respiratory problems. The two groups differed significantly in the timing of wheezing (late onset in low-HSU vs early in high-HSU) and future total costs (stable vs increased). CONCLUSIONS One in ten children had high respiratory care use in early life. Such information can help identify high-risk young children in a large population, monitor their long-term health, and inform resource allocation.
Collapse
|