Evaluation of patient preference and willingness to pay for attributes of maintenance medication for chronic obstructive pulmonary disease (COPD)

A Systematic and Critical Review of Discrete Choice Experiments in Asthma and Chronic Obstructive Pulmonary Disease

Background

Regulators have called for greater emphasis on the role of the patient voice to inform medical product development and decision making, and expert guidelines and reports for asthma and chronic obstructive pulmonary disease (COPD) both explicitly recommend the consideration of patient preferences in the management of these diseases. Discrete choice experiments (DCEs) are commonly used to quantify stakeholders’ treatment preferences and estimate the trade-offs they are willing to make between outcomes such as treatment benefits and risks.

Objective

The aim of this systematic literature review is to provide an up-to-date and critical review of DCEs published in asthma and COPD; specifically, we aim to evaluate the subject of preference studies conducted in asthma and COPD, what attributes have been included, stakeholders’ preferences, and the consistency in reporting of instrument development, testing and reporting of results.

Methods

A systematic review of published DCEs on asthma and COPD treatments was conducted using Embase, Medline and the Cochrane Database of Systematic Reviews. Studies were included if they included a DCE conducted in a relevant population (e.g. patients with asthma or COPD or their caregivers, asthma or COPD-treating clinicians, or the general population), and reported quantitative outcomes on participants’ preferences. Study characteristics were summarised descriptively, and descriptive analyses of attribute categories, consistency in reporting on key criteria, and stakeholder preferences were undertaken.

Results

A total of 33 eligible studies were identified, including 28 unique DCEs. The majority (n = 20; 71%) of studies were conducted in a patient sample. Studies focused on inhaler treatments, and included attributes in five key categories: symptoms and treatment benefits (n = 23; 82%), treatment convenience (n = 19; 68%), treatment cost (n = 17; 61%), treatment risks (n = 13; 46%), and other (n = 10; 36%). Symptoms and treatment benefits were the attributes most frequently ranked as important to patients (n = 26, 72%), followed by treatment risks (n = 7, 39%). Several studies (n = 9, 32%) did not qualitatively pre-test their DCE, and a majority did not report the uncertainty in estimated outcomes (n = 18; 64%).

Conclusions

DCEs in asthma and COPD have focused on treatment benefits and convenience, with less evidence generated on participants’ risk tolerance. Quality criteria and reporting standards are needed to promote study quality and ensure consistency in reporting between studies.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40271-021-00536-w.

[GRADE guidelines 20: Assessing the certainty of evidence in the importance of outcomes or values and preferences-inconsistency, imprecision, and other domains]

OBJECTIVE

To provide Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) guidance for assessing inconsistency, imprecision, and other domains for the certainty of evidence about the relative importance of outcomes.

STUDY DESIGN AND SETTING

We applied the GRADE domains to rate the certainty of evidence in the importance of outcomes to several systematic reviews, iteratively reviewed draft guidance, and consulted GRADE members and other stakeholders for feedback.

RESULTS

We describe the rationale for considering the remaining GRADE domains when rating the certainty in a body of evidence for the relative importance of outcomes. As meta-analyses are not common in this context, inconsistency and imprecision assessments are challenging. Furthermore, confusion exists about inconsistency, imprecision, and true variability in the relative importance of outcomes. To clarify this issue, we suggest that the true variability is neither equivalent to inconsistency nor imprecision. Specifically, inconsistency arises from population, intervention, comparison and outcome and methodological elements that should be explored and, if possible, explained. The width of the confidence interval and sample size inform judgments about imprecision. We also provide suggestions on how to detect publication bias and discuss the domains to rate up the certainty.

CONCLUSION

We provide guidance and examples for rating inconsistency, imprecision, and other domains for a body of evidence describing the relative importance of outcomes.

"Willingness to Pay": The Value Attributed to Program Location by Pulmonary Rehabilitation Participants

The "contingent valuation" method is used to quantify the value of services not available in traditional markets, by assessing the monetary value an individual ascribes to the benefit provided by an intervention. The aim of this study was to determine preferences for home or center-based pulmonary rehabilitation for participants with chronic obstructive pulmonary disease (COPD) using the "willingness to pay" (WTP) approach, the most widely used technique to elicit strengths of individual preferences. This is a secondary analysis of a randomized controlled equivalence trial comparing center-based and home-based pulmonary rehabilitation. At their final session, participants were asked to nominate the maximum that they would be willing to pay to undertake home-based pulmonary rehabilitation in preference to a center-based program. Regression analyses were used to investigate relationships between participant features and WTP values. Data were available for 141/163 eligible study participants (mean age 69 [SD 10] years, n = 82 female). In order to undertake home-based pulmonary rehabilitation in preference to a conventional center-based program, participants were willing to pay was mean $AUD176 (SD 255) (median $83 [IQR 0 to 244]). No significant difference for WTP values was observed between groups (p = 0.98). A WTP value above zero was related to home ownership (odds ratio [OR] 2.95, p = 0.02) and worse baseline SF-36 physical component score (OR 0.94, p = 0.02). This preliminary evidence for WTP in the context of pulmonary rehabilitation indicated the need for further exploration of preferences for treatment location in people with COPD to inform new models of service delivery.

Research and Healthcare Priorities of Individuals Living with COPD

This study describes the research and healthcare priorities of individuals living with COPD. On an online survey, individuals living with COPD assigned a percentage of funding to 22 research priorities and a percentage of time spent communicating with a healthcare provider to 24 healthcare priorities, indicating which topics were most important. For each research and healthcare priority, we examined the selection frequency of the priority and used chi-square analyses to examine differences in priority selection by quartiles of airflow obstruction (percent predicted forced expiratory volume in 1-sec (FEV₁%predicted)) and breathlessness burden and exacerbation risk. Based on participants' responses (N = 148, 47% women; Mean ± Standard Deviation age = 68 ± 9 yrs) relief of breathlessness was the most often selected research (76% of respondents) and healthcare priority (61% of respondents). It was selected most often, regardless of disease severity or breathlessness burden and exacerbation risk. We found differences for disease severity and breathlessness burden and exacerbation risk in some research priorities (e.g., to improve the maximal amount of exercise of adults living with COPD in and out of the home (χ²₍₃₎ = 9.97, Cramer's V =.28) and healthcare priorities (e.g., increase your ability to exercise (χ²₍₃₎ = 9.72, Cramer's V =.27)). This study provides empirical evidence that relief of breathlessness is a top research and healthcare priority for individuals living with COPD. Future healthcare and research activities should align with the priorities of individuals with COPD to improve their care by minimizing disease/symptom burden and optimizing health-related quality of life.

Prioritization and Refinement of Patient-Informed Value Elements as Attributes for Chronic Obstructive Pulmonary Disease Treatment Preferences

BACKGROUND AND OBJECTIVE

Formative research studies can inform stated-preference instrument development to quantify the importance of various attributes of healthcare treatments. The objective of this study was to elicit from patients with chronic obstructive pulmonary disease the prioritization of an established set of patient-informed value elements.

METHODS

Using an iterative mixed-methods study design, we engaged individuals living with chronic obstructive pulmonary disease in Phase 1 value element elicitation and Phase 2 language refinement. Study participants were recruited from March to July 2019. Four guided activities, administered in an online instrument, elicited individual preferences for 40 disease-agnostic value elements that were aligned with treatment, outcomes, or care process. Responses from the guided activities were summarized and then presented to a patient advocate and additional patient participants for further refinement of the value elements and the phrasing.

RESULTS

Twenty-three participants, 18 male and five female, mean age of 66 years (standard deviation = 7) were enrolled in Phase 1. Participant responses informed the selection of eight elements as the key candidates for the Phase 2 language refinement: Side Effects, New Therapeutic Option, Available Treatment, Appropriateness of Care, Predictable Healthcare Needs, Physical Activities: Endurance and Symptom Control, and Explanation of Treatment. With feedback from a patient advocate and additional patient participants, elements were refined, rephrased, or modified and this list was narrowed to six value elements (Side Effects, New Therapeutic Option, Willingness to Pay, Physical Activities, Explanation of Treatment, and Access to Care) to serve as attributes in a conceptual framework for a future quantitative stated-preference instrument.

CONCLUSIONS

This patient-engaged formative work identified patients with chronic obstructive pulmonary disease key attributes of value-based decision making that underpin benefit-risk trade-offs between physical endurance, treatment side effects, care access, and cost. This study illustrates an iterative process for eliciting and refining a comprehensive list of value elements, resulting in a subgroup of elements important to a specific patient population.

Chinese Medicine for Chronic Obstructive Pulmonary Disease: A Pilot Study on Patient Preferences

PURPOSE

The patient's preference plays an important role in clinical practice. There currently is no available evidence regarding the perception and attitudes of patients with chronic obstructive pulmonary disease (COPD) towards the use of Chinese medicine (CM) approaches. This study was designed to explore preferences and factors associated with CM among COPD patients.

PATIENTS AND METHODS

A pilot survey was conducted among COPD patients using a structured, pre-tested questionnaire. The perceptions of CM therapies (including herbal medicine, non-pharmacotherapies), and expected clinical outcomes were investigated based on patient preference. Factors associated with preference of treatment scenarios were estimated in order of importance.

RESULTS

Thirty patients were enrolled in the survey, including 27 males and 3 females. Two-thirds of the patients preferred integrative Chinese and Western medicine for the treatment of COPD. Chinese patent medicines and CM decoction therapy were more popular than CM injections. The preferred non-drug therapy was point application, followed by acupuncture, Tai chi, or Qigong. More than 70% of patients reported that important clinical outcomes were improvements in lung function (77%) and dyspnea, cough, and sputum symptoms (73%), followed by exercise endurance (50%). Besides clinical efficacy, costs and side effects were also important factors for treatment selection.

CONCLUSION

This pilot study showed that Chinese patent medicine and CM decoctions were preferred options for complementary medicines to combine with routine pharmacotherapy for COPD treatment according to the patients' preferences. The improvement of dyspnea, cough symptoms, and lung function was the most desired clinical outcomes for patients. Quicker symptom relief, lower costs, and fewer side effects were key attributes for the treatment selection. Further research with a larger sample size is needed to definitively address the comprehensive conclusion.

Treatment Preferences of Patients with Chronic Obstructive Pulmonary Disease: Results from Qualitative Interviews and Focus Groups in the United Kingdom, United States, and Germany

BACKGROUND

A wide range of therapeutic regimens, including single-inhaler triple therapies (SITTs), are now available for the maintenance treatment of chronic obstructive pulmonary disease (COPD). Thus, an improved understanding of patient preferences may be valuable to inform physician prescribing decisions. This study was performed to assess the factors considered by patients when making decisions about their COPD treatments using qualitative techniques.

METHODS

In the United Kingdom, United States and Germany, individual qualitative interviews (n=10 per country) and focus groups (1 per country; [United Kingdom, n=4; United States, n=6; Germany, n=6 participants]) were conducted. Interviews and focus groups were semi‑structured, lasting approximately 60 minutes, and focused on treatment preferences. Data were analyzed according to emerging themes identified from the interviews; qualitative thematic analysis of the data was performed using specialist software.

RESULTS

In interviews and focus groups, efficacy, ease of use, and lower frequency of use were favored attributes for current treatment, while side effects, medication taste, and more complex administration techniques were key dislikes. In interviews, most participants would consider a switch in medication, mainly for improved efficacy, but also to reduce medication frequency or following physician advice. Overall, efficacy and ease of use were the 2 most important attributes reported in interviews in all 3 countries.

CONCLUSION

Patients with COPD have preferences for certain attributes of medication, highlighting the multi-faceted nature of treatment effectiveness and the importance of the delivery device.These results were subsequently used to inform the design of a discrete choice experiment.

Maintenance inhaler therapy preferences of patients with asthma or chronic obstructive pulmonary disease: a discrete choice experiment

BACKGROUND

A variety of maintenance inhaler therapies are available to treat asthma and COPD. Patient-centric treatment choices require understanding patient preferences for the alternative therapies.

METHODS

A self-completed web-based discrete choice experiment was conducted to elicit patient preferences for inhaler device and medication attributes. Selection of attributes was informed by patient focus groups and literature review.

RESULTS

The discrete choice experiment was completed by 810 patients with asthma and 1147 patients with COPD. Patients with asthma most valued decreasing the onset of action from 30 to 5 min, followed by reducing yearly exacerbations from 3 to 1. Patients with COPD most and equally valued decreasing the onset of action from 30 to 5 min and reducing yearly exacerbations from 3 to 1. Both patients with asthma and patients with COPD were willing to accept an additional exacerbation in exchange for a 15 min decrease in onset of action and a longer onset of action in exchange for a lower risk of adverse effects from inhaled corticosteroids. Patients with asthma and COPD valued once-daily over twice-daily dosing, pressurised inhalers over dry powder inhalers and non-capsule priming over single-use capsules, although these attributes were not valued as highly as faster onset of action or reduced exacerbations.

CONCLUSIONS

The most important maintenance inhaler attributes for patients with asthma and COPD were fast onset of symptom relief and a lower rate of exacerbations. Concerns about safety of inhaled corticosteroids and device convenience also affected patient preferences but were less important.

Patient preference for chronic obstructive pulmonary disease (COPD) treatment inhalers: a discrete choice experiment in France

OBJECTIVES

Understanding inhaler preferences may contribute to improving adherence in COPD patients and improving long-term outcomes. This study aims to identify and quantify preferences for convenience-related inhaler attributes in French moderate-to-severe COPD patients, with discrete choice experiment (DCE) methodology.

METHODS

Attributes were defined from a literature search, clinician and patient interviews: shape, dose insertion, dose preparation, dose release, dose confirmation, dose counter and reusability. An online DCE was conducted in respondents with self-reported COPD stage 2-4 recruited through a panel. The study questionnaire included twelve choice scenarios per respondent and questions on patient characteristics, treatment and disease severity. Statistical analyses used a mixed logit regression model with random effects. Utility scores were estimated for four types of inhalers: Inhaler A - soft mist inhaler; Inhaler B - reusable soft mist inhaler; Inhaler C - multi-dose dry powder inhaler; and Inhaler D - single dose dry powder inhaler.

RESULTS

The study was completed by 153 patients (50 females); respondents were 50.4 years old on average; 13 different inhaler devices were reported. The most preferred inhaler is L-shaped, has dose preparation with capsule insertion and a dose counter, and is reusable. Inhaler profiles A and B had the highest utilities (mean of 1.2533 and 0.9578 respectively) compared to inhaler C (0.6315) and D (0.2200).

CONCLUSIONS

This study showed statistically significant results that the strongest drivers of preference in French users of inhalation devices for COPD are shape, dose counter and reusability. Convenience-related characteristics are important to patients and should be taken into account by clinicians prescribing these devices.

Discrete Choice Experiments in Health Economics: Past, Present and Future

OBJECTIVES

Discrete choice experiments (DCEs) are increasingly advocated as a way to quantify preferences for health. However, increasing support does not necessarily result in increasing quality. Although specific reviews have been conducted in certain contexts, there exists no recent description of the general state of the science of health-related DCEs. The aim of this paper was to update prior reviews (1990-2012), to identify all health-related DCEs and to provide a description of trends, current practice and future challenges.

METHODS

A systematic literature review was conducted to identify health-related empirical DCEs published between 2013 and 2017. The search strategy and data extraction replicated prior reviews to allow the reporting of trends, although additional extraction fields were incorporated.

RESULTS

Of the 7877 abstracts generated, 301 studies met the inclusion criteria and underwent data extraction. In general, the total number of DCEs per year continued to increase, with broader areas of application and increased geographic scope. Studies reported using more sophisticated designs (e.g. D-efficient) with associated software (e.g. Ngene). The trend towards using more sophisticated econometric models also continued. However, many studies presented sophisticated methods with insufficient detail. Qualitative research methods continued to be a popular approach for identifying attributes and levels.

CONCLUSIONS

The use of empirical DCEs in health economics continues to grow. However, inadequate reporting of methodological details inhibits quality assessment. This may reduce decision-makers' confidence in results and their ability to act on the findings. How and when to integrate health-related DCE outcomes into decision-making remains an important area for future research.

A systematic review of how patients value COPD outcomes

Our objective was to summarise systematically all research evidence related to how patients value outcomes in chronic obstructive pulmonary disease (COPD).We conducted a systematic review (systematic review registration number CRD42015015206) by searching PubMed, Embase, PsycInfo and CINAHL, and included reports that assessed the relative importance of outcomes from COPD patients' perspective. Two authors independently determined the eligibility of studies, abstracted the eligible studies and assessed risk of bias. We narratively summarised eligible studies, meta-analysed utilities for individual outcomes and assessed the certainty of evidence using the Grading of Recommendations, Assessment, Development and Evaluations approach.We included 217 quantitative studies. Investigators most commonly used utility measurements of outcomes (n=136), discrete choice exercises (n=13), probability trade-off (n=4) and forced choice techniques (n=46). Patients rated adverse events as important but on average, less so than symptom relief. Exacerbation and hospitalisation due to exacerbation are the outcomes that COPD patients rate as most important. This systematic review provides a comprehensive registry of related studies.

Process value of care safety: women's willingness to pay for perinatal services

Objective

To evaluate the process value of care safety from the patient's view in perinatal services.

Design

Cross-sectional survey.

Settings

Fifty two sites of mandated public neonatal health checkup in 6 urban cities in West Japan.

Participants

Mothers who attended neonatal health checkups for their babies in 2011 (n = 1316, response rate = 27.4%).

Main Outcome Measure

Willingness to pay (WTP) for physician-attended care compared with midwife care as the process-related value of care safety. WTP was estimated using conjoint analysis based on the participants' choice over possible alternatives that were randomly assigned from among eight scenarios considering attributes such as professional attendance, amenities, painless delivery, caesarean section rate, travel time and price.

Results

The WTP for physician-attended care over midwife care was estimated 1283 USD. Women who had experienced complications in prior deliveries had a 1.5 times larger WTP.

Conclusions

We empirically evaluated the process value for safety practice in perinatal care that was larger than a previously reported accounting-based value. Our results indicate that measurement of process value from the patient's view is informative for the evaluation of safety care, and that it is sensitive to individual risk perception for the care process.

Adherence to Maintenance Medications among Older Adults with Chronic Obstructive Pulmonary Disease. The Role of Depression

RATIONALE

Among individuals with chronic obstructive pulmonary disease (COPD), depression is one of the most common yet underrecognized and undertreated comorbidities. Although depression has been associated with reduced adherence to maintenance medications used in other conditions, such as diabetes, little research has assessed the role of depression in COPD medication use and adherence.

OBJECTIVES

The objective of this study was to assess the impact of depression on COPD maintenance medication adherence among a nationally representative sample of Medicare beneficiaries newly diagnosed with COPD.

METHODS

We used a 5% random sample of Medicare administrative claims data to identify beneficiaries diagnosed with COPD between 2006 and 2010. We included beneficiaries with 2 years of continuous Medicare Parts A, B, and D coverage and at least two prescription fills for COPD maintenance medications after COPD diagnosis. We searched for prescription fills for inhaled corticosteroids, long-acting β-agonists, and long-acting anticholinergics and calculated adherence starting at the first fill. We modeled adherence to COPD maintenance medications as a function of new episodes of depression, using generalized estimated equations.

MEASUREMENTS AND MAIN RESULTS

Our primary outcome was adherence to COPD maintenance medications, measured as proportion of days covered. The exposure measure was depression. Both COPD and depression were assessed using diagnostic codes in Part A and B data. Covariates included sociodemographics, as well as clinical markers, including comorbidities, COPD severity, and depression severity. Of 31,033 beneficiaries meeting inclusion criteria, 6,227 (20%) were diagnosed with depression after COPD diagnosis. Average monthly adherence to COPD maintenance medications was low, peaking at 57% in the month after first fill and decreasing to 35% within 6 months. In our adjusted regression model, depression was associated with decreased adherence to COPD maintenance medications (odds ratio, 0.93; 95% confidence interval, 0.89-0.98).

CONCLUSIONS

New episodes of depression decreased adherence to maintenance medications used to manage COPD among older adults. Clinicians who treat older adults with COPD should be aware of the development of depression, especially during the first 6 months after COPD diagnosis, and monitor patients' adherence to prescribed COPD medications to ensure best clinical outcomes.

Inhalation device options for the management of chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is characterized by chronic respiratory symptoms and airflow limitation, resulting from abnormalities in the airway and/or damage to the alveoli. Primary care physicians manage the healthcare of a large proportion of patients with COPD. In addition to determining the most appropriate medication regimen, which usually includes inhaled bronchodilators with or without inhaled corticosteroids, physicians are charged with optimizing inhalation device selection to facilitate effective drug delivery and patient adherence. The large variety of inhalation devices currently available present numerous challenges for physicians that include: (1) gaining knowledge of and proficiency with operating different device classes; (2) identifying the most appropriate inhalation device for the patient; and (3) providing the necessary education and training for patients on device use. This review provides an overview of the inhalation device types currently available in the United States for delivery of COPD medications, including information on their successful operation and respective advantages and disadvantages, factors to consider in matching a device to an individual patient, the need for device training for patients and physicians, and guidance for improving treatment adherence. Finally, the review will discuss established and novel tools and technology that may aid physicians in improving education and promoting better adherence to therapy.

Evaluation and quantification of treatment preferences for patients with asthma or COPD using discrete choice experiment surveys

INTRODUCTION

To investigate treatment preferences of patients with asthma or chronic obstructive pulmonary disease (COPD), previously identified influential treatment factors were used to develop a discrete choice experiment (DCE) survey.

METHODS

An internet-based survey was conducted with UK-resident adults (recruited using a commercial panel) who were currently receiving asthma/COPD treatment and had not taken part in the previous phase of this study (qualitative interviews to understand patient burden, life impact and treatment preferences). Participants ranked treatment attributes from 0 (extremely important) to 8 (not at all important) and chose between hypothetical treatments for asthma/COPD with differing attributes. Preferences for each condition were assessed separately using a mixed logit regression model.

RESULTS

Most of the 302 participants had not well-controlled asthma (Asthma Control Test™ scores ≤19/25) or experienced a high impact of COPD (COPD Assessment Test™ scores >20/40). Participant views were generally similar for both conditions; having well-controlled symptoms all day was considered most important. All treatment attributes significantly influenced preferences; the most preferred were no sleep disturbance (versus waking up often) and low cost. Subsequent preferences (with some variation between asthma/COPD) were for treatments with easy/convenient use, no flare ups/exacerbations, that enabled desired physical activities, well-controlled symptoms all day, that enabled desired social activities, and low medication frequency.

CONCLUSIONS

These eight treatment attributes, valued by patients with asthma or COPD, are important for healthcare professionals to consider regarding treatment options and for future therapy development. Our DCE results broadly reinforce the findings from qualitative interviews in the first study phase.

Patient preferences for dry powder inhaler attributes in asthma and chronic obstructive pulmonary disease in France: a discrete choice experiment

Background

Dry powder inhalers (DPIs) are often used in asthma and chronic obstructive pulmonary disease (COPD) therapies. Using the discrete choice experiment (DCE) methodology, this study conducted in France was designed to assess patients’ preferences for different attributes of DPIs.

Methods

Attributes of DPIs were defined based on a literature review, patient focus group discussions and interviews with healthcare professionals (qualitative phase of the study). An online survey was then conducted among French patients with asthma or COPD to elicit patient preferences and willingness to pay (WTP) for these attributes using the DCE methodology (quantitative phase). A fractional factorial design including three blocks of 12 choice sets was created. Each choice set comprised three alternatives: two fictitious inhalers and the patient’s current inhaler. Marginal utilities were estimated using a ranked ordered logit model. Interactions between attributes and disease (asthma or COPD) were tested.

Results

Six DPI attributes were defined based on the qualitative phase: ease of use/fool-proof priming; accurate and easy-to-read dose counter; dose confirmation; hygiene of the mouthpiece; flexibility of the device handling; ability to use the inhaler with breathing difficulties. Overall, 201 patients with asthma and 93 with COPD were included in the online survey. Patients with asthma placed most value on an inhaler that requires one step for dose preparation (WTP €4.83 [95% CI: €3.77–€5.90], relative to an inhaler requiring four steps) and one that could be used during episodes of breathing difficulties (WTP €4.49 [95% CI: €2.95–€6.02]). Patients with COPD placed most value on an inhaler that could be used during episodes of breathing difficulties (WTP €7.70 [95% CI: €5.65–€9.76]) and on the accuracy of the dose counter (WTP €5.87 [95% CI: €3.98–€ 7.77]).

Conclusion

This study suggests that asthma and COPD patients would be willing to change their inhaler if they were offered the option of a new inhaler with improved characteristics and they place a high value on an inhaler with ease of use during breathing difficulty episodes.

Electronic supplementary material

The online version of this article (doi:10.1186/s12890-017-0439-x) contains supplementary material, which is available to authorized users.

Does co-payment for inhaler devices affect therapy adherence and disease outcomes? A historical, matched cohort study

BACKGROUND

Adherence to asthma and chronic obstructive pulmonary disease (COPD) treatment has been shown to depend on patient-level factors, such as disease severity, and medication-level factors, such as complexity. However, little is known about the impact of prescription charges - a factor at the health care system level. This study used real-life data to investigate whether co-payment affects adherence (implementation and persistence) and disease outcomes in patients with asthma or COPD.

METHODS

A matched, historical cohort study was carried out using two UK primary care databases. The exposure was co-payment for prescriptions, which is required for most patients in England but not in Scotland. Two comparison cohorts were formed: one comprising patients registered at general practices in England and the other comprising patients registered in Scotland. Patients aged 20-59 years with asthma, or 40-59 years with COPD, who were initiated on fluticasone propionate/salmeterol xinafoate, were included, matched to patients in the opposite cohort, and followed up for 1 year following fluticasone propionate/salmeterol xinafoate initiation. The primary outcome was good adherence, defined as medication possession ratio ≥80%, and was analyzed using conditional logistic regression. Secondary outcomes included exacerbation rate.

RESULTS

There were 1,640 patients in the payment cohort, ie, England (1,378 patients with asthma and 262 patients with COPD) and 619 patients in the no-payment cohort, ie, Scotland (512 patients with asthma and 107 patients with COPD). The proportion of patients with good adherence was 34.3% and 34.9% in the payment and no-payment cohorts, respectively, across both disease groups. In a multivariable model, no difference in odds of good adherence was found between the cohorts (odds ratio, 1.04; 95% confidence interval, 0.85-1.27). There was also no difference in exacerbation rate.

CONCLUSION

There was no difference in adherence between matched patients registered in England and Scotland, suggesting that prescription charges do not have an impact on adherence to treatment.

Meeting the challenge of COPD care delivery in the USA: a multiprovider perspective

The burden of chronic obstructive pulmonary disease (COPD) in the USA continues to grow. Although progress has been made in the the development of diagnostics, therapeutics, and care guidelines, whether patients' quality of life is improved will ultimately depend on the actual implementation of care and an individual patient's access to that care. In this Commission, we summarise expert opinion from key stakeholders-patients, caregivers, and medical professionals, as well as representatives from health systems, insurance companies, and industry-to understand barriers to care delivery and propose potential solutions. Health care in the USA is delivered through a patchwork of provider networks, with a wide variation in access to care depending on a patient's insurance, geographical location, and socioeconomic status. Furthermore, Medicare's complicated coverage and reimbursement structure pose unique challenges for patients with chronic respiratory disease who might need access to several types of services. Throughout this Commission, recurring themes include poor guideline implementation among health-care providers and poor patient access to key treatments such as affordable maintenance drugs and pulmonary rehabilitation. Although much attention has recently been focused on the reduction of hospital readmissions for COPD exacerbations, health systems in the USA struggle to meet these goals, and methods to reduce readmissions have not been proven. There are no easy solutions, but engaging patients and innovative thinkers in the development of solutions is crucial. Financial incentives might be important in raising engagement of providers and health systems. Lowering co-pays for maintenance drugs could result in improved adherence and, ultimately, decreased overall health-care spending. Given the substantial geographical diversity, health systems will need to find their own solutions to improve care coordination and integration, until better data for interventions that are universally effective become available.

Intravenous versus Subcutaneous Drug Administration. Which Do Patients Prefer? A Systematic Review

BACKGROUND

Intravenous (IV) drug delivery is commonly used for its rapid administration and immediate drug effect. Most studies compare IV to subcutaneous (SC) delivery in terms of safety and efficacy, but little is known about what patients prefer.

METHODS

A systematic review was conducted by searching seven electronic databases for articles published up to February 2014. Included studies were randomized controlled trials (RCTs) and/or crossover designs investigating patient preference for SC versus IV administration. The risk of bias in the RCTs was determined using the Cochrane Collaboration tool. Reviewers independently extracted data and assessed the risk of bias. Any discrepancies were resolved by consensus.

RESULTS

The search identified 115 publications, but few (6/115) met the inclusion criteria. Patient populations and drugs investigated were diverse. Four of six studies demonstrated a clear patient preference for SC administration. Main factors associated with SC preference were time saving and the ability to have treatment at home. Only three studies used study-specific instruments to measure preference.

CONCLUSIONS

Results suggest that patients prefer SC over IV delivery. Patient preference has clearly been neglected in clinical research, but it is important in medical decision making when choosing treatment methods as it has implications for adherence and quality of life. If the safety and efficacy of both administration routes are equivalent, then the most important factor should be patient preference as this will ensure optimal treatment adherence and ultimately improve patient experience or satisfaction. Future drug efficacy and safety studies should include contemporaneous, actual patient preference where possible, utilizing appropriate measures.