Cost-effectiveness analysis: fluticasone furoate/umeclidinium/vilanterol for the treatment of moderate to severe chronic obstructive pulmonary disease from the perspective of the Chilean public health system

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is an inflammatory lung disease characterized by long-term breathing problems and airflow limitations. International guidelines recommend using bronchodilators like long-acting beta- and muscarinic antagonists, and inhalational corticosteroids.

OBJECTIVES

The cost-effectiveness of single-inhaler triple therapy containing fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI) was compared to the treatments Fluticasone Furoate/Vilanterol (FF/VI), Umeclidinio/Vilanterol (UMEC/VI) and Fluticasone Propionate 250 mcg/Salmeterol 25mcg + Tiotropio 18 mcg (FP/SAL/TIO) for patients with COPD from the Chilean public health system perspective.

METHODS

A cost-effectiveness analysis was performed, including a deterministic and probabilistic sensitivity analysis over a 25-year time horizon. Two scenarios were assessed to study the effect of a 3%-discount for costs and outcomes on FF/UMEC/VI.

RESULTS

The incremental cost-effectiveness (ICER) of FF/UMEC/VI versus FF/VI was $10,076/QALY, being a cost-effective alternative to a threshold of one Gross Domestic Product per capita (GDPpc), while versus FP/SAL/TIO the ICER increased to $50,288/QALY, showing to be a non-cost effective alternative to 1 GDPpc, but at a threshold of 3 GDPpc.

CONCLUSION

FF/UMEC/VI appears a cost-effective intervention for treating COPD compared to FF/VI. However, FF/UMEC/VI compared to FP/SAL/TIO showed an ICER above the threshold of 1 GDPpc, but, in comparison with lower price, the ICER was below 3 GDPpc.

La evaluación con el cuestionario COPD-PS y el dispositivo portátil Vitalograph COPD - 6 como estrategia para el diagnóstico temprano de la EPOC en la atención primaria

Objetivo: evaluar el uso del cuestionario COPD-PS y el dispositivo portátil Vitalograph COPD-6, como estrategia para el diagnóstico temprano de la enfermedad pulmonar obstructiva crónica (EPOC) en dos unidades de atención primaria de la empresa social del estado (E.S.E): Metrosalud, Medellín-Colombia en 2017. Métodos: estudio transversal de detección temprana de la EPOC, en personas mayores de 35 años sin diagnóstico previo de la enfermedad u otras complicaciones respiratorias subyacentes, a las cuales se les aplicó la prueba de tamizaje de COPD-PS para identificar factores de riesgo respiratorio y, posteriormente, la prueba de volumen espiratorio forzado (VEF1/VEF6) con el dispositivo portátil Vitalograph COPD-6. Resultados: de 1.485 pruebas de tamizaje COPD-PS, 198 presentaron un puntaje igual o superior a 4, por lo que se les realizó la prueba con el dispositivo Vitalograph. De los cuales, 147 (74,2 %) resultaron positivos. Discusión: el subregistro de la EPOC se describe actualmente como un grave problema mundial. El uso del cuestionario COPD-PS para la identificación de pacientes con factores de riesgo y del Vitalograph COPD-6 como prueba de función pulmonar, pueden ser herramientas útiles para implementar una estrategia efectiva en la reducción del subregistro de la EPOC.

Prevalence of chronic obstructive pulmonary disease (COPD) not diagnosed in a population with cardiovascular risk factors

BACKGROUND AND OBJECTIVE

The magnitude of undiagnosed COPD in our population with cardiovascular risk factors (CVRF) is unknown. The objective of this study was to estimate the prevalence of undiagnosed COPD and its specific characteristics in a population with CVRF.

MATERIALS AND METHODS

Study the prevalence of COPD in patients with CVRF. Spirometry was performed between 01/01/2015 and 12/31/2016 and the percentage of patients with COPD, who had not previously been diagnosed, was determined. Each patient's variables of interest were recorded; the records of patients who had spirometry showing COPD were checked to confirm whether a diagnosis had been recorded or not. The association of undiagnosed COPD with different independent variables was determined with adjusted odds ratio (aOR) by non conditional logistic regression models.

RESULTS

2,295 patients with CVRF were studied. The overall prevalence of COPD was 14.5%. An underdiagnosis of 73.3% was observed. Newly diagnosed COPD vs. undiagnosed COPD showed to be higher in women (74.1% vs. 36.0%; P=.081), non-smokers (21.3% vs. 12.4%; P=.577), mild cases (GOLD1) (42.6% vs. 32.4%, P=.008) and cases with lower than average HbA1c (5.5% vs. 5.6%; P=.008) and uric acid (5.1mg/dL vs. 5.6mg/dL; P=.011). The variables associated with undiagnosed COPD were: women (aOR=1.27; 95%CI: 0.74-2.17; P=.383); age (aOR=0.94; 95%CI: 0.87-0.99; P=.018); smokers (smoker/non-smoker) (aOR=0.47; 95%CI: 0.22-1.01; P=.054) and HbA1c (%) (aOR=0.45; 95%CI: 0.23-0.88; P=.019).

CONCLUSIONS

The under-diagnosis of COPD is very high. The contact patients aged between 50 and 65 years-old who have CVRF with their health system should be reassessed, and they need to ask for a spirometry.

Bronchodilator treatment for COPD in primary care of four Latin America countries: The multinational, cross-sectional, non-interventional PUMA study

BACKGROUND AND OBJECTIVE

Bronchodilators (BDs) are the cornerstone of COPD treatment. However, their underuse has been reported in real-life studies. PUMA is a primary-care study from Argentina, Colombia, Venezuela and Uruguay that could help understand the BD use in terms of frequency for long-acting (LA-BD) and short-acting (SA-BD) BDs alone or associated with corticosteroids (CS), and the use as-needed or on regular basis.

METHODS

This is a multicentre, multinational, cross-sectional, non-interventional study including no randomised primary-care centres from each country (total 57 centres) without connection with respiratory specialists. Subjects attending routine visits, at-risk for COPD (≥40 years, current or former smokers or exposed to biomass) completed a questionnaire and performed spirometry. COPD was defined as post-BD FEV1/FVC<0.70 and by the lower limit of normal (LLN). Prior physician diagnosis of emphysema, chronic bronchitis or COPD was also determined.

RESULTS

1743 patients were interviewed, 1540 completed spirometry, 309 had COPD by post-BD FEV1/FVC<0.70, 226 by LLN, and 102 had prior medical diagnosis. A total of 77/309 COPD patients by spirometry (24.9%) used BD (3.6% LA-BDs), 15.2% used BD + CS (13.6% LA-BD + CS). Among these patients, SA-BDs (monotherapy) were the most commonly used medication both as-needed (4.5%) and on a regular basis (17.5%). Similar findings were observed using the LLN criteria. In those with prior medical diagnosis, 66/102 (64.7%) used BDs (9.8% LA-BD), and 25.6% used BD + CS (13.6% LA-BD + CS); among them SA-BDs were the most commonly medication used as-needed (9%) and on a regular basis (48.1%). Having health insurance with medication coverage increased the use of BDs.

CONCLUSIONS

Up to 60% of COPD patients by spirometry and 10% of those with prior medical diagnosis attending a primary care sample of four Latin American countries did not use BDs. LA-BDs are widely underused on a regular-basis (2.6% and 8.3% of patients with spirometric and medical-diagnosis, respectively) This represents a considerable gap between guideline recommendations and BD prescribing pattern in these centres.

The epidemiology and burden of COPD in Latin America and the Caribbean: systematic review and meta-analysis

Abstract Background: In the developing world, COPD continues to be an under studied, diagnosed and treated disorder. In the present study, we analyzed the prevalence, mortality and resource utilization of COPD in Latin America and the Caribbean (LAC) in order to guide future research and public policies.

METHODS

A systematic review and meta-analysis was performed following MOOSE and PRISMA guidance. We searched CENTRAL, MEDLINE, EMBASE, LILACS, countries' Ministries of Health, proceedings, and doctoral theses from January 1990 to October 2012. We included studies with a validated definition of COPD that assessed the incidence, prevalence, use of health care resources or costs since 1985. Using EROS, a web-based software, pairs of reviewers independently selected, performed quality assessment (using a STROBE-based checklist) and extracted the study data. Discrepancies were resolved by consensus. Arcsine transformations and random-effects model were used for proportion meta-analyses.

RESULTS

26 articles met entry criteria. The pooled COPD prevalence defined by GOLD criteria (11 cities, 6 countries) was 13.4% (95%CI, 10.1-17.1). Most patients suffer mild or moderate COPD and were undertreated according to international guidelines. The prevalence increased by age and was 1.75 times higher in men than women. 35 of every 1,000 hospitalizations were due to COPD, most of high economic cost, and the COPD in-hospital mortality ranged from 6.7% to 29.5%.

CONCLUSIONS

COPD burden in LAC is high, especially for men and older persons; however few persons had severe disease. COPD patients often received inappropriate treatment and had high exacerbation and hospitalization rates leading to high economic costs.

[Annual Review of COPD]

There have been significant advances in the knowledge in the thoracic and extrathoracic aspects of chronic obstructive pulmonary disease (COPD) in the past few years. COPD is associated with numerous comorbidities, the prevalences of which have recently been evaluated. Dyspnea has been shown to be associated with neuropsychiatric disturbances, such as anxiety. Muscular dysfunction has been associated with inflammation and oxidative stress, in which respiratory muscle satellite cells play an important role in repair. Respiratory rehabilitation and physiotherapy must form an important part of individualised patient treatment analogous to the pharmacological treatment. As regards acute exacerbations, infection is the cause of 75% of them, sputum characteristics and the suspicion of Pseudomonad being key factors in the antibiotic treatment. Questions, such as markers which can detect the origin of the infection, prognostic factors, or the role of short stay pneumology units, are of particular importance. The variability in COPD treatments and the lack of suitable international clinical guidelines, continue to be subjects of debate. To the poor use of the treatment schemes in the guidelines, can be added the irregular uses of inhaled medication, the insufficient use of medical advice or the low intervention in cigarette smoking in all age groups.

Use of respiratory medication in five Latin American cities: The PLATINO study

BACKGROUND

There is scanty information regarding respiratory medication prescription pattern in Latin America. We examined the use of bronchodilators and corticosteroids in a population-based study conducted in five Latin American cities.

METHODS

Medication use was derived from questions regarding the use of medication "to help breathing" within the previous 12 months, type of medicine, and frequency of use. To minimize the possibility of overdiagnosis, we used postbronchodilator FEV(1)/FVC<0.70 plus FEV(1)<80% as the definition of obstruction.

RESULTS

Interviews were completed in 5571 subjects from 6711 eligible individuals, and spirometry was performed in 5314 subjects. There were 360 (6.5%) treated subjects and 5211 not treated. Treated subjects were more likely to be older, women, unemployed, have higher tobacco consumption, higher body mass index, higher FEV(1) reversibility and airway obstruction. They were also more likely to report prior spirometry, prior diagnosis of COPD, asthma or tuberculosis, and more respiratory symptoms. Over half of treated subjects had neither obstruction nor FEV(1) reversibility, and approximately 30% reported no prior diagnosis of asthma or COPD. Prior respiratory diagnoses and wheezing were more strongly associated with treatment than objective measures of airway obstruction.

CONCLUSIONS

The use of bronchodilators and/or corticosteroids is common in the general population aged 40 years or older, with over one-half of treated subjects using them without being obstructed.