Suboptimal medical therapy in COPD: exploring the causes and consequences

Characteristics Associated with Spirometry Guideline Adherence in VA Patients Hospitalized with Chronic Obstructive Pulmonary Disease

BACKGROUND

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommends at least annual spirometry for patients with chronic obstructive pulmonary disease (COPD). Since spirometry acquisition is variable in clinical practice, identifying characteristics associated with annual spirometry may inform strategies to improve care for patients with COPD.

METHODS

We included veterans hospitalized for COPD at Veterans Health Administration (VHA) facilities from 10/2012 to 09/2015. Our primary outcome was spirometry within 1 year of COPD hospitalization. Patient demographics, health factors, and comorbidities as well as practice and geographic variables were identified using Corporate Data Warehouse; provider characteristics were obtained from the Survey of Healthcare Experiences of Patients. We used logistic regression with a random intercept to account for potential clustering within facilities.

RESULTS

Spirometry was completed 1 year before or after hospitalization for 20,683/38,148 (54.2%) veterans across 114 facilities. Patients with spirometry were younger, (mean=67.2 years (standard deviation (SD)=9.3) vs. 69.4 (10.3)), more likely non-white (21.3% vs. 19.7%), and more likely to have comorbidities (p<0.0001 for asthma, depression, and post-traumatic stress disorder). Pulmonary clinic visit was most strongly associated with spirometry (odds ratio (OR)=3.14 [95% confidence interval 2.99-3.30]). There was no association for facility complexity. In a secondary analysis including provider-level data (3862 patients), results were largely unchanged. There was no association between primary care provider age, gender, or type (physician vs. advanced practice registered nurse vs. physician assistant) and spirometry.

CONCLUSION

In a cohort of high-risk COPD patients, just over half completed spirometry within 1 year of hospitalization. Pulmonary clinic visit was most strongly associated with 1-year spirometry, though provider variables were not. Spirometry completion for high-risk COPD patients remains suboptimal and strategies to improve post-hospitalization care for patients not seen in pulmonary clinic should be developed to ensure guideline concordant care.

Smart dry powder inhalers and intelligent adherence management

Adherence to inhaled treatments is a complex challenge for patients with chronic obstructive pulmonary disease (COPD) and asthma, it not only involves following the prescribed treatment plans but also administering the medications correctly. When using a dry powder inhaler (DPI), the inhalation flow is particularly critical. Patients frequently fail to use a rapid enough onset and fast enough inhalation when using DPIs. At the same time, there is increasing pressure on physicians to switch patients to DPIs, to minimise the environmental impact of pMDI propellants. This makes it critical to understand whether a patient will maintain or improve disease control by using their new inhaler correctly. However, it is challenging for health care professionals to understand how a patient behaves away from the clinic. Therefore, it would be beneficial to obtain real-world data through the use of monitoring tools, i.e., "smart inhalers". This paper reviews the technologies used to monitor DPIs, how effective they have been in a clinical setting, and how well these have been adopted by patients and health care providers.

Suboptimal Peak Inspiratory Flow and Critical Inhalation Errors are Associated with Higher COPD-Related Healthcare Costs

Purpose

To assess the relationship between suboptimal Peak Inspiratory Flow (sPIF), inhalation technique errors, and non-adherence, with Healthcare Resource Utilisation (HCRU) in Chronic Obstructive Pulmonary Disease (COPD) patients receiving maintenance therapy via a Dry Powder Inhaler (DPI).

Patients and methods

The cross-sectional, multi-country PIFotal study included 1434 COPD patients (≥40 years) using a DPI for maintenance therapy. PIF was measured with the In-Check DIAL G16, and sPIF was defined as a typical PIF lower than required for the device. Inhalation technique was assessed by standardised evaluation of video recordings and grouped into 10 steps. Patients completed the “Test of Adherence to Inhalers” questionnaire. HCRU was operationalised as COPD-related costs for primary healthcare, secondary healthcare, medication, and total COPD-related costs in a 1-year period.

Results

Participants with sPIF had higher medication costs compared with those with optimal PIF (cost ratio [CR]: 1.07, 95% CI [1.01, 1.14]). Multiple inhalation technique errors were associated with increased HCRU. Specifically, “insufficient inspiratory effort” with higher secondary healthcare costs (CR: 2.20, 95% CI [1.37, 3.54]) and higher total COPD-related costs (CR: 1.16, 95% CI 1.03–1.31). “no breath-hold following the inhalation manoeuvre (<6 s)” with higher medication costs (CR: 1.08, 95% CI [1.02, 1.15]) and total COPD-related costs (CR 1.17, 95% CI [1.07, 1.28]), and “not breathing out calmly after inhalation” with higher medication costs (CR: 1.19, 95% CI [1.04, 1.37]). Non-adherence was not significantly associated with HCRU.

Conclusion

sPIF and inhalation technique errors were associated with higher COPD-related healthcare utilisation and costs in COPD patients on DPI maintenance therapy.

Physical Functioning in Patients with Chronic Obstructive Pulmonary Disease Treated with Tiotropium/Olodaterol Respimat in Routine Clinical Practice in Italy

Introduction

Clinical studies have shown significant improvements in exercise capacity in patients with chronic obstructive pulmonary disease (COPD) who are treated with a tiotropium/olodaterol fixed-dose combination (FDC). However, the effects of this treatment, which is administered in a single device, on physical functioning in a real-life setting of patients with COPD had not been fully determined.

Methods

An open-label, observational study was conducted in 309 patients with COPD from 29 sites across Italy who received tiotropium/olodaterol FDC for 6 weeks. Physical functioning was evaluated using the Physical Functioning Questionnaire (PF-10). The primary endpoint was the proportion of patients with therapeutic success, defined as a ten-point increase in the PF-10 score from the baseline visit. Secondary endpoints were absolute changes in PF-10 score from baseline visit, the patient’s general condition assessed by the Physician’s Global Evaluation (PGE) score, and patient satisfaction with treatment, inhaling and handling of the device.

Results

According to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) multimodality assessment, most patients were allocated to groups B (44.4%) and D (24.5%). Comorbidities were present in 73.9% of the patients. The primary endpoint was reached in more than half of the patients (52.5%), especially in groups B and D of GOLD. Patients’ satisfaction with treatment, inhaling and handling of device was high, with a range of more than 86% to more than 89%, and very high in both groups B and D. The rates of drug-related adverse events were very low.

Conclusions

This real-life study showed that the tiotropium/olodaterol FDC treatment delivered via the Respimat device improves physical functioning and general patients’ condition and is associated with a high degree of satisfaction and very low rates of drug-related adverse events, regardless of the group they belong to and their comorbidities.

Clinical Trial ID

NCT03003494.

Electronic supplementary material

The online version of this article (10.1007/s41030-020-00122-9) contains supplementary material, which is available to authorized users.

Limited overlap in significant hits between genome-wide association studies on two airflow obstruction definitions in the same population

BACKGROUND

Airflow obstruction is a hallmark of chronic obstructive pulmonary disease (COPD), and is defined as either the ratio between forced expiratory volume in one second and forced vital capacity (FEV1/FVC) < 70% or < lower limit of normal (LLN). This study aimed to assess the overlap between genome-wide association studies (GWAS) on airflow obstruction using these two definitions in the same population stratified by smoking.

METHODS

GWASes were performed in the LifeLines Cohort Study for both airflow obstruction definitions in never-smokers (NS = 5071) and ever-smokers (ES = 4855). The FEV1/FVC < 70% models were adjusted for sex, age, and height; FEV1/FVC < LLN models were not adjusted. Ever-smokers models were additionally adjusted for pack-years and current-smoking. The overlap in significantly associated SNPs between the two definitions and never/ever-smokers was assessed using several p-value thresholds. To quantify the agreement, the Pearson correlation coefficient was calculated between the p-values and ORs. Replication was performed in the Vlagtwedde-Vlaardingen study (NS = 432, ES = 823). The overlapping SNPs with p < 10- 4 were validated in the Vlagtwedde-Vlaardingen and Rotterdam Study cohorts (NS = 1966, ES = 3134) and analysed for expression quantitative trait loci (eQTL) in lung tissue (n = 1087).

RESULTS

In the LifeLines cohort, 96% and 93% of the never- and ever-smokers were classified concordantly based on the two definitions. 26 and 29% of the investigated SNPs were overlapping at p < 0.05 in never- and ever-smokers, respectively. At p < 10- 4 the overlap was 4% and 6% respectively, which could be change findings as shown by simulation studies. The effect estimates of the SNPs of the two definitions correlated strongly, but the p-values showed more variation and correlated only moderately. Similar observations were made in the Vlagtwedde-Vlaardingen study. Two overlapping SNPs in never-smokers (NFYC and FABP7) had the same direction of effect in the validation cohorts and the NFYC SNP was an eQTL for NFYC-AS1. NFYC is a transcription factor that binds to several known COPD genes, and FABP7 may be involved in abnormal pulmonary development.

CONCLUSIONS

The definition of airflow obstruction and the population under study may be important determinants of which SNPs are associated with airflow obstruction. The genes FABP7 and NFYC(-AS1) could play a role in airflow obstruction in never-smokers specifically.

Adherence to inhaled therapy and its impact on chronic obstructive pulmonary disease (COPD)

Background

COPD is a treatable disease with increasing prevalence worldwide. Treatment aims to stop disease progression, to improve quality of life, and to reduce exacerbations. We aimed to evaluate the association of the stage of COPD on adherence to inhaled therapy and the relationship between adherence and COPD exacerbations.

Methods

A retrospective analysis of patients hospitalized for acute exacerbation of COPD in a tertiary care hospital in Upper Austria and discharged with a guideline conform inhaled therapy was performed. Follow-up data on medical utilization was recorded for the subsequent 24 months. Adherence to inhaled therapy was defined according to the percentage of prescribed inhalers dispensed to the patient and classified as complete (> 80%), partial (50–80%) or low (< 50%).

Results

Out of 357 patients, 65.8% were male with a mean age of 66.5 years and a mean FEV₁ of 55.0%pred. Overall, 35.3% were current smokers, and only 3.9% were never-smokers. In 77.0% inhaled triple therapy (LAMA + LABA + ICS) was prescribed. 33.6% showed complete adherence to their therapy (33.2% in men, 34.4% in women), with a mean age of 67.0 years. Mean medication possession ratio by GOLD spirometry class I – IV were 0.486, 0.534, 0.609 and 0.755, respectively (p = 0.002). Hence, subjects with complete adherence to therapy had a significantly lower FEV₁ compared to those with low adherence (49.2%pred. vs 59.2%pred., respectively; p <  0.001).

The risk of exacerbations leading to hospitalization was 10-fold higher in GOLD spirometry class IV compared to GOLD spirometry class I, which was even more evident in multivariate analysis (OR 13.62).

Conclusion

Complete adherence to inhaled therapy was only seen in 33.6% and was higher among those with more severe COPD.

Trial registration

Not applicable.

Incorporating telemedicine into the integrated care of the COPD patient a summary of an interdisciplinary workshop held in Stresa, Italy, 7-8 September 2017

This report is a summary of a workshop focusing on using telemedicine to facilitate the integrated care of chronic obstructive pulmonary disease (COPD). Twenty-five invited participants from 8 countries met for one and one-half days in Stresa, Italy on 7-8 September 2017, to discuss this topic. Participants included physiotherapists, nurses, a nurse practitioner, and physicians. While evidence-based data are always at the center of sound inference and recommendations, at this point in time the science behind telemedicine in COPD remains under-developed; therefore, this document reflects expert opinion and consensus. While telemedicine has great potential to expand and improve the care of our COPD patients, its application is still in its infancy. While studies have demonstrated its effectiveness in some patient-centered outcomes, the results are by no means consistently positive. Whereas this tool may potentially reduce health care costs by moving some medical interventions from centralized locations in to patient's home, its cost-effectiveness has had mixed results and telemonitoring has yet to prove its worth in the COPD population. These discordant results should not be unexpected in view of patient complexity and the heterogeneity of telemedicine. This is reflected in the very limited support offered by the National Health Services to a wider application of telemedicine in the integrated care of COPD patients. However, this situation should challenge us to develop the necessary science to clarify the role of telemedicine in the medical management of our patients, providing a better and definitive scientific basis to this approach.

Integrated Care in Chronic Obstructive Pulmonary Disease and Rehabilitation

Individuals with advanced chronic obstructive pulmonary disease (COPD) often have complex medical problems that require more than simple pharmacological therapy to optimize outcomes. Comprehensive care is necessary to meet the substantial burdens, not just from the primary respiratory disease process itself, but also those imposed by its systemic manifestations and comorbidities. These problems are intensified in the peri-exacerbation period, especially for newly discharged patients. Pulmonary rehabilitation, with its interdisciplinary, patient-centered and holistic approach to management, and integrated care, adding coordination or transition of care to the chronic care model, are useful approaches to meeting these complex issues.

Adherence to GOLD guidelines in real-life COPD management in the Puglia region of Italy

Background

COPD is a disease associated with significant economic burden. It was reported that Global initiative for chronic Obstructive Lung Disease (GOLD) guideline-oriented pharmacotherapy improves airflow limitation and reduces health care costs. However, several studies showed a significant dissociation between international recommendations and clinicians’ practices. The consequent reduced diagnostic and therapeutic inappropriateness has proved to be associated with an increase in costs and a waste of economic resources in the health sector. The aim of the study was to evaluate COPD management in the Puglia region. The study was performed in collaboration with the pulmonology centers and the Regional Health Agency (AReS Puglia).

Methods

An IT platform allowed the pulmonologists to enter data via the Internet. All COPD patients who visited a pneumological outpatient clinic for the first time or for regular follow-ups or were admitted to a pneumological department for an exacerbation were considered eligible for the study. COPD’s diagnosis was confirmed by a pulmonologist at the moment of the visit. The project lasted 18 months and involved 17 centers located in the Puglia region.

Results

Six hundred ninety-three patients were enrolled, evenly distributed throughout the region. The mean age was 71±9 years, and 85% of them were males. Approximately 23% were current smokers, 63% former smokers and 13.5% never smokers. The mean post-bronchodilator forced expiratory volume in 1 second was 59%±20% predicted. The platform allowed the classification of patients according to the GOLD guidelines (Group A: 20.6%, Group B: 32.3%, Group C: 5.9% and Group D: 39.2%), assessed the presence and severity of exacerbations (20% of the patients had an exacerbation defined as mild [13%], moderate [37%] and severe [49%]) and evaluated the appropriateness of inhalation therapy at the time of the visit. Forty-nine percent of Group A patients were following inappropriate therapy; in Group B, 45.8% were following a therapy in contrast with the guidelines. Among Group C patients, 41.46% resulted in triple combination therapy, whilê14% of Group D patients did not have a therapy or were following an inappropriate therapy. In conclusion, 30% of all patients evaluated had been following an inadequate therapy. Subsequently, an online survey was developed to inquire about the reasons for the results obtained. In particular, we investigated the reasons why 30% of our population did not follow the therapy suggested by the GOLD guidelines: 1) why was there an excessive use of inhaled corticosteroids, 2) why a significantly high percentage was inappropriately treated with triple therapy and 3) why a consistent percentage (11%) of Group D patients were not treated at all.

Conclusion

The data provides an overview on the management of COPD in the region of Puglia (Italy) and represents a resource in order to improve appropriateness and reduce the waste of health resources.

Patients' perspectives and preferences in the choice of inhalers: the case for Respimat(®) or HandiHaler(®)

Poor inhaler technique hampers the efficacy of drug therapy in asthma and chronic obstructive pulmonary disease. Not only does this affect individual patient care, but it also impacts on the wider health care economics associated with these conditions. Treatment guidelines recommend a systematic approach to drug class selection; however, standardization of inhaler selection is currently difficult owing to the complexity of the interaction between the inhaler device and the patient. Specifically, individual patient preference can influence how successful a treatment is overall. This article reviews inhaler devices from the patient perspective, with a particular focus on the dry powder inhaler HandiHaler(®) and Respimat(®) Soft Mist™ Inhaler. It discusses factors that influence device preference and treatment compliance and reviews tools that can aid health care professionals to better match inhaler devices to individual patients' needs.

Non-pharmacological treatments for COPD

Chronic obstructive pulmonary disease (COPD) affects roughly 10% of the global population and is growing in prevalence annually. COPD is characterized by progressive non-reversible narrowing of airways mainly due to cigarette smoking. Therapeutic interventions aimed at altering this progressive disease course can largely be grouped into pharmacological or non-pharmacological therapies. The focus of this paper is on the non-pharmacological aspects of COPD management, reviewing the current literature to provide an evidence-based management approach. Non-pharmacological therapies reviewed in this article include the implementation of comprehensive care models utilizing a coordinated multidisciplinary team, tele-monitoring and patient-centred approach to optimize COPD care and improve compliance. Preventing progression of COPD via smoking cessation remains of paramount importance, and newer therapeutic options including electronic cigarettes show promise in small studies as cessation aids. COPD has systemic manifestations that can be ameliorated with the enrollment in pulmonary rehabilitation programmes, which focus on exercise endurance to improve dyspnoea and quality of life. Advanced therapeutics for COPD includes lung volume reduction surgery for a pre-specified cohort and minimally invasive bronchoscopic valves that in recent reviews show promise. Lastly, patients on maximal COPD therapy with progressive disease can be referred for lung transplantation; however, this often requires a highly selected and motivated patient and care team. Survival rates for lung transplantation are improving; thus, this procedure remains a viable option as more expertise and experience are gained.

Relevance of dosage in adherence to treatment with long-acting anticholinergics in patients with COPD

Introduction

The aim of this study was to assess the degree of adherence for two standard regimens for administrating anticholinergic drugs (12 and 24 hours) in patients with chronic obstruction of the airflow and to establish whether the use of a once-daily dose improves the level of treatment adherence.

Methods

We used long-acting anticholinergics (LAMAs) as a study variable, and included the entire health area of Castile-La Mancha, numbering 2,100,998 inhabitants, as the study population. We analyzed a total of 16,446 patients who had been prescribed a LAMA between January 1, 2013 and December 31, 2013. The follow-up period, based on a centralized system of electronic prescription management, was extended until December 2014.

Results

During 2013, the medication collected was 7.4%–10.7% higher than indicated by labeling. This was very similar for all LAMAs, irrespective of the patient’s sex, the molecule, the device, and the drug dosage. We did not observe seasonal variations in the consumption of LAMAs, nor did we detect differences between prescription drugs for once-daily (every 24 hours) versus twice-daily (every 12 hours) administration, between the different molecules, or between different types of inhalers for the same molecule. The results were similar in 2014.

Conclusion

The principal conclusion of this study is that, in an area with a centralized management system of pharmacological prescriptions, adherence to treatment with LAMAs is very high, irrespective of the molecules or inhalation device. We did not find that patients who used twice-daily medication had a lower adherence.

Severe COPD Exacerbation Risk and Long-Acting Bronchodilator Treatments: Comparison of Three Observational Data Analysis Methods

OBJECTIVE

Results from three observational methods for assessing effectiveness of long-acting bronchodilator therapies for reducing severe exacerbations of chronic obstructive pulmonary disease (COPD) were compared: intent-to-treat (ITT), as protocol (AP), and an as-treated analysis that utilized a marginal structural model (MSM) incorporating time-varying covariates related to treatment adherence and moderate exacerbations.

STUDY DESIGN AND SETTING

Severe exacerbation risk was assessed over a 2-year period using claims data for patients aged ≥40 years who initiated long-acting muscarinic antagonist (LAMA), inhaled corticosteroid/long-acting beta-agonist (ICS/LABA), or triple therapy (LAMA + ICS/LABA).

RESULTS

A total of 5475 COPD patients met inclusion criteria. Six months post-initiation, 53.5 % of patients discontinued using any therapy. The ITT analysis found an increased severe exacerbation risk for triple therapy treatment (hazard ratio [HR] 1.24; 95 % confidence interval [CI] 1.00-1.53). No increased risk was found in the AP (HR 1.00; 95 % CI 0.73-1.36), or MSM analyses (HR 1.11; 95 % CI 0.68-1.81). The MSM highlighted important associations among post-index events.

CONCLUSION

Neglecting to adjust for treatment discontinuation may produce biased risk estimates. The MSM approach is a promising tool to compare chronic disease management by illuminating relationships between treatment decisions, adherence, patient choices, and outcomes.

A nurse-led intervention study: Promoting compliance with Diskus Inhaler use in asthma patients

AIM

To examine the impact of a nurse-led patient assessment and education programme in promoting compliance with inhaler use in asthma patients.

DESIGN

A quasi-experimental pre-test and post-test design.

METHODS

A sample of asthmatic patients (N = 21) were recruited from the population of patients attending an asthma clinic. An Inhaler Proficiency Schedule (IPS) was developed and validated. At each visit, participants were requested to demonstrate their inhaler technique. The participants were investigated as to their confidence level with self-administration of their inhaler and adherence to prescribed doses. This information was recorded on a Patient-Reported Behaviour (PRB) questionnaire.

RESULTS

Technique, compliance and patient confidence levels improved with nurse-led education repeated over three visits; this was sustained on measurement at 6 months following completion of the education programme.

Improving medication adherence in chronic obstructive pulmonary disease: a systematic review

Adherence to medication among individuals with chronic obstructive pulmonary disease (COPD) is suboptimal and has negative impacts on survival and health care costs. No systematic review has examined the effectiveness of interventions designed to improve medication adherence. Electronic databases Medline and Cochrane were searched using a combination of MeSH and keywords. Eligible studies were interventions with a primary or secondary aim to improve medication adherence among individuals with COPD published in English. Included studies were assessed for methodological quality using the Effective Practice and Organisation of Care (EPOC) criteria. Of the 1,186 papers identified, seven studies met inclusion criteria. Methodological quality of the studies was variable. Five studies identified effective interventions. Strategies included: brief counselling; monitoring and feedback about inhaler use through electronic medication delivery devices; and multi-component interventions consisting of self-management and care co-ordination delivered by pharmacists and primary care teams. Further research is needed to establish the most effective and cost effective interventions. Special attention should be given to increasing patient sample size and using a common measure of adherence to overcome methodological limitations. Interventions that involve caregivers and target the healthcare provider as well as the patient should be further explored.

Clinical and economic impact of non-adherence in COPD: a systematic review

BACKGROUND

Medication for Chronic Obstructive Pulmonary Disease (COPD) has shown to substantially reduce symptoms and slow progression of disease. However, non-adherence to medication is common and associated with worsened clinical and economic outcomes.

OBJECTIVE

The objective of this study was to perform a systematic review of published literature to assess the impact of non-adherence to COPD medication on clinical and economic outcomes.

METHODS

A search in PubMed and Web of Science databases was conducted of original studies published from database inception to 2012. Studies must report on the association between adherence to COPD medication and outcomes, published in English in peer-reviewed journals and full texts needed to be available.

RESULTS

Twelve full articles were included in the review. Most studies were retrospective database studies. Seven studies reported on the association between adherence and clinical outcomes, two on mortality, three on costs, four on quality of life and one on work productivity. Results indicated a clear association between adherence and both clinical and economic outcomes. Evidence from studies revealed increased hospitalizations, mortality, quality of life and loss of productivity among non-adherent patients.

CONCLUSION

This review revealed a clear association between non-adherence to COPD medication and worsened clinical and economic outcomes making non-adherent patients a priority for cost-effective interventions.

New clinical insights into chronic obstructive pulmonary disease and their implications for pharmacoeconomic analyses

Chronic obstructive pulmonary disease (COPD) is one of the leading causes of death and disability worldwide, but before the development of several new pharmacological treatments little could be done for COPD patients. Recognition that these new treatments could significantly improve the prognosis for COPD patients has radically changed clinical management guidelines from a palliative philosophy to an aggressive approach intended to reduce chronic symptoms, improve quality of life and prolong survival. These new treatments have also sparked interest in COPD cost-effectiveness research. Most COPD cost-effectiveness studies have been based on clinical trial populations, limited to direct medical costs, and used standard analysis methods such as Markov modelling, and they have usually found that newer therapies have favourable cost effectiveness. However, new insights into the clinical progression of COPD bring into question some of the assumptions underlying older analyses. In this review, we examine clinical factors unique to COPD and recent changes in clinical perspectives that have important implications for pharmacoeconomic analyses. The main parameters explored include (i) the high indirect medical costs for COPD and their relevance in assessing the societal benefits of new therapy; (ii) the importance of acute deteriorations in COPD, known as exacerbations, and approaches to modelling the cost benefit of exacerbation reduction; (iii) quality/utility instruments for COPD; (iv) the prevalence of co-morbid conditions and confounding between COPD and co-morbid disease utilization; (v) the limitations of Markov modelling; and (vi) the problem of outliers.

Adherence to current guidelines for chronic obstructive pulmonary disease (COPD) among patients treated with combination of long-acting bronchodilators or inhaled corticosteroids

Background

To estimate the potential cost savings by following the current Global Initiative for Chronic Obstructive Lung Disease (GOLD) guideline recommendations in patients being treated for chronic obstructive pulmonary disease (COPD) with the combination of long-acting β₂-agonist (LABA), long-acting muscarinic antagonist (LAMA) or inhaled corticosteroids (ICS).

Methods

The Geisinger Health System (GHS) database was utilized to identify subjects between January 1, 2004 to March 12, 2007. The index date was based on the first prescription of a LAMA plus LABA, LAMA plus LABA/ICS, or LABA plus ICS. Patients were included in the study if they: had a COPD diagnosis; had data representative of treatment 12 months prior to and 12 months post index date; were 40 years of age or over; had no prior diagnosis for asthma; and had pulmonary function test (PFT) data. We examined the baseline characteristics of these patients along with their healthcare resource utilization. Based on PFT data within 30 days of the index date, a subgroup was classified as adhering or non-adhering to GOLD guidelines.

Results

A total of 364 subjects could be classified as adhering or non-adherent to current GOLD guidelines based on their PFT results. The adherent subgroup received COPD medications consistent with current GOLD guidelines. Of the LAMA plus LABA cohort, 25 patients adhered and 39 patients were non-adherent to current GOLD guidelines. In the cohort of LABA plus ICS, 74 patients were adherent and 180 patients non-adherent to current GOLD guidelines. In the cohort of LAMA plus LABA/ICS, 21 patients were adherent and 25 patients non-adherent to current GOLD guidelines. GOLD adherence was associated with mean total cost of all services savings of $5,889 for LAMA plus LABA, $3,330 for LABA + ICS, and $10,217 for LAMA plus LABA/ICS cohorts.

Conclusion

Staging of COPD with a PFT and adherence to current GOLD guidelines was associated with lower costs in subjects with moderate to severe COPD. Appropriate use of LAMA plus LABA, LABA plus ICS, and LAMA plus LABA/ICS has economic as well as clinical benefits for patients and payers.

Epidemiology and management of common pulmonary diseases in older persons

Pulmonary disease prevalence increases with age and contributes to morbidity and mortality in older patients. Dyspnea in older patients is often ascribed to multiple etiologies such as medical comorbidities and deconditioning. Common pulmonary disorders are frequently overlooked as contributors to dyspnea in older patients. In addition to negative impacts on morbidity and mortality, quality of life is reduced in older patients with uncontrolled, undertreated pulmonary symptoms. The purpose of this review is to discuss the epidemiology of common pulmonary diseases, namely pneumonia, chronic obstructive pulmonary disease, asthma, lung cancer, and idiopathic pulmonary fibrosis in older patients. We will review common clinical presentations for these diseases and highlight differences between younger and older patients. We will also briefly discuss risk factors, treatment, and mortality associated with these diseases. Finally, we will address the relationship between comorbidities, pulmonary symptoms, and quality of life in older patients with pulmonary diseases.

Impact of pharmaceutical care on health outcomes in patients with COPD

BACKGROUND

Chronic obstructive pulmonary disease (COPD) treatment goals are often not achieved despite the availability of many effective treatments. Furthermore, clinical pharmacist interventions to improve clinical and humanistic outcomes in COPD patients have not yet been explored and few randomized controlled trials have been reported to evaluate the impact of pharmaceutical care on health outcomes in patients with COPD.

OBJECTIVE

The aim of the present study was to evaluate the impact of pharmaceutical care intervention, with a strong focus on self-management, on a range of clinical and humanistic outcomes in patients with COPD.

SETTING

Outpatient COPD Clinic at the Royal Medical Services Hospital.

METHOD

In a randomised, controlled, prospective clinical trial, a total of 133 COPD patients were randomly assigned to intervention or control group. A structured education about COPD and management of its symptoms was delivered by the clinical pharmacist for patients in the intervention group. Patients were followed up at 6 months during a scheduled visit. Effectiveness of the intervention was assessed in terms of improvement in health-related quality of life, medication adherence, disease knowledge and healthcare utilization. Data collected at baseline and at the 6 month assessment was coded and entered into SPSS(®) software version 17 for statistical analysis. A P value of <0.05 was considered statistically significant.

MAIN OUTCOME MEASURE

The primary outcome measure was health-related quality of life improvement. All other data collected including healthcare utilization, COPD knowledge and medication adherence formed secondary outcome measures.

RESULTS

A total of 66 patients were randomized to the intervention group and 67 patients were randomized to the control group. Although the current study failed to illustrate significant improvement in health-related quality of life parameters, the results indicated significant improvements in COPD knowledge (P < 0.001), medication adherence (P < 0.05), medication beliefs (P < 0.01) and significant reduction in hospital admission rates (P < 0.05) in intervention patients when compared with control group patients at the end of the study.

CONCLUSION

The enhanced patient outcomes as a result of the pharmaceutical care programme in the present study demonstrate the value of an enhanced clinical pharmacy service in achieving the desired health outcomes for patients with COPD.

Outcomes associated with initiation of tiotropium or fluticasone/salmeterol in patients with chronic obstructive pulmonary disease

INTRODUCTION

Adherence to long-acting bronchodilator therapy for management of chronic obstructive pulmonary disease (COPD) is a critical clinical and cost issue. Low adherence is associated with relatively higher exacerbation rates and illness burden.

PURPOSE

To compare adherence between patients with COPD initiating therapy on tiotropium or fluticasone/salmeterol and examine the association between adherence and respiratory-related costs.

PATIENTS AND METHODS

This retrospective claims data analysis evaluated patients initiating tiotropium or combination fluticasone/salmeterol from December 1, 2004 to December 31, 2005. Patients had ≥1 COPD diagnosis (International Classification of Diseases, 9th Revision, Clinical Modification [ICD-9-CM] 491.xx, 492.x, 496) and were observed during 6-month pre-index and variable (12-18-month) post-index periods. Outcomes were adherence to and discontinuation of therapy, and respiratory-related inpatient, medical, and total health care costs. Adherence was medication possession ratio ≥0.80. Discontinuation, adherence, and costs were analyzed with Cox proportional hazards regression, logistic regression, and generalized linear model regressions, respectively. Regressions controlled for demographic, sociodemographic, and health status factors.

RESULTS

The study population comprised 1561 tiotropium and 2976 fluticasone/salmeterol patients. In unadjusted comparisons: 19.5% and 8.5% of tiotropium and fluticasone/salmeterol patients, respectively, were adherent (P < 0.001); tiotropium patients versus fluticasone/salmeterol patients had higher mean respiratory-related pharmacy costs (US$1080 versus US$974, P = 0.002) and health care costs (US$3751 versus US$2932, P = 0.031). Regression analysis showed tiotropium patients were 31.6% less likely to discontinue therapy (95% confidence interval [CI]: 0.64-0.73) and had 2.25 times higher odds of adherence (CI: 1.85-2.73) versus fluticasone/salmeterol patients. The associations between index therapy and costs were not significant. Adherence versus nonadherence was associated with: 46.9% higher health care costs (CI: 1.13-1.91); 37.1% lower medical costs (CI: 0.43-0.91); and 53.4% lower inpatient costs (CI: 0.30-0.72).

CONCLUSION

Patients with COPD initiating long-acting bronchodilator therapy were more likely to be adherent to tiotropium than to fluticasone/salmeterol. Adherence to either tiotropium or to fluticasone/salmeterol was associated with lower respiratory-related medical and inpatient costs, and with higher respiratory-related total health care costs.

Variation in adherence with Global Initiative for Chronic Obstructive Lung Disease (GOLD) drug therapy guidelines: a retrospective actuarial claims data analysis

OBJECTIVES

Chronic obstructive pulmonary disease (COPD) is an irreversible and often progressive disease that requires lifelong adherence to complicated drug therapy regimens. The well established Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines recommend specific drug therapy protocols, yet patient adherence to drug therapy and physician adherence to prescribing guidelines is reported to be suboptimal. In this claims based analysis of COPD patients, drug therapy treatment patterns including inhaled corticosteroids and long acting bronchodilator use were evaluated by COPD severity level.

METHODS

A cohort of patients with COPD (without co-existing asthma) was identified in Thomas Reuters MarketScan Commercial Database 2007 (diagnosis codes 491.xx, 492.xx, 496.xx). Using one year (2007) of claims data, a COPD severity risk score was calculated for each patient using established claim logic. Severity levels of mild, moderate, severe, and very severe were established to mimic the GOLD severity levels. Each patient's claim experience was examined for inhaled corticosteroid and long acting bronchodilator use for compliance with GOLD guidelines.

RESULTS

Prevalence of COPD (without co-existing asthma) was 0.7% (44,366 cases). The distribution of COPD subjects into claim based severity levels was 30% mild, 53% moderate, 14% severe and 3% very severe. Claims for inhaled corticosteroid therapy were identified for 8% of mild and 19% of moderate COPD patients; claims for short acting bronchodilator therapy without concomitant use of long acting bronchodilators were identified for 20% of moderate, 14% of severe and 8% of very severe COPD patients; and claims for single long acting bronchodilator therapy in combination with inhaled corticosteroid therapy were identified for 12% of moderate, 19% of severe and 2% of very severe COPD patients.

CONCLUSIONS

This analysis suggests less than optimal compliance with recommended drug therapy treatment for COPD patients based on GOLD guidelines. This study further suggests the utility of claims data analyses for providing reasonable aggregate distributions of COPD severity which allows for health plans and disease management programs to stratify COPD patients by severity level and examine opportunities for improved drug therapy management. Study findings should be considered in the context of the study limitations.

Inappropriate overuse of inhaled corticosteroids for COPD patients: impact on health costs and health status

The aim of this study was to evaluate the relationship between inappropriate overuse of inhaled corticosteroids and self-reported health status and the annual cost of patients with stable chronic obstructive pulmonary disease (COPD) recruited in the primary-care setting. An observational, crossover, descriptive study was conducted. Patients with stable COPD and aged ≥40 years, evaluated in primary care, were included. Data collected were demographic variables, clinical characteristics, self-reported health status (SF-12), the severity of the illness, treatment, and health-care resource utilization in the past year. The patients were recruited during a period of 3 months (from January 1 to March 31, 2003). Use was considered inappropriate when corticosteroids were prescribed by physicians for patients not meeting criteria for its use as recommended in guidelines. A total of 10,711 patients [75.6% males; mean age = 67.1 (SD = 9.66) years] were evaluated. Disease severity was mild in 35.5% of the cases, moderate in 53.4%, and severe in 11.2%. Among them, 3,697 (34.5%) subjects were prescribed inhaled corticosteroids or drug combinations containing such therapies, with a rate of inappropriate use of 18.2%. Physical health status was significantly lower among patients showing inappropriate corticosteroids use: 37.35 (SD = 9.53) vs. 40.7 (SD = 9.80) (p < 0.05). The annual cost per patient of COPD management was significantly higher in the group with inappropriate inhaled corticosteroids use: <euro>1,590 (SD = 1,834) vs. <euro>1,157 (SD = 1,536) (p < 0.05). Factors statistically associated with inappropriate use of corticosteroids were educational attainment [OR: 2.77 (95% CI: 1.36-5.63) for nonuniversity training], a history of heart disease [OR: 1.42 (95% CI: 1.02-1.97)], depression [OR: 1.47 (95% CI: 1.05-2.05)], any allergy [OR 1.69 (95% CI: 1.13-2.54)], and physical health status [OR 0.97 (95% CI: 0.96-0.98)]. Lack of adherence to the recommended criteria for using inhaled corticosteroids therapy in the management of COPD patients was associated with lower self-reported health status and higher costs. Factors statistically associated with inappropriate use of corticosteroids were educational attainment, a history of heart disease, depression, any allergy, and physical health status.

Adherence to controller therapy for chronic obstructive pulmonary disease: a review

OBJECTIVE

While several studies have examined adherence to controller medications for the treatment of COPD, few systematic reviews have taken the translational step to identifying important and necessary areas for further research. The objective of this study was to review data on the outcomes of adherence to various controller therapies in patients with COPD in an effort to help prescribers understand adherence properties for each therapy.

RESEARCH DESIGN AND METHODS

This is a systematic review of studies investigating adherence to an array of controller pharmaceutical regimens. The studies were obtained from PubMed during 2008 and 2009 using the following key words: chronic obstructive pulmonary disease, COPD, adherence, controller medication, and persistence. Only articles encompassing adherence or persistence data to controller medications and published after 1990 were utilized.

RESULTS

After the search results were filtered for only the articles that pertained to adherence or persistence measurements in COPD, 35 articles remained; and finally, discounting those articles not published in English, articles which did not compare treatments for COPD, as well as those which were review articles, ten applicable articles remained. Each of these found low levels of medication adherence and/or persistence among patients receiving medications for COPD. Patients receiving fluticasone/salmeterol (FSC) and tiotropium (TIO) for treatment showed the highest adherence among all controller medications. Patients who were married, older, and white were more likely to adhere to their medications.

CONCLUSION

Characteristics of the medication used (i.e. dosing schedule, formulation, etc.) as well as patient characteristics affect the adherence/persistence to medications for the treatment of COPD. Further patient education is necessary in order to effectively improve disease management and patient outcomes in COPD. There is a need for future research and educational efforts to improve adherence in COPD and more clearly identify specific behavioral and treatment characteristics associated with specific COPD medications that can facilitate adherence.

Treatment of COPD: relationships between daily dosing frequency, adherence, resource use, and costs

BACKGROUND

Medication adherence is important in managing COPD. This study analyzed real-world use of inhaled medications for COPD to characterize relationships between daily dosing frequency, adherence, healthcare resource utilization, and cost.

METHODS

This retrospective study used a large administrative claims database covering 8 million insured lives in the US from 1999 to 2006. Patients were stratified based on the recommended daily dosing frequency of their first COPD drug claim following COPD diagnosis. Adherence was measured using proportion of days covered (PDC) over 12 months following treatment initiation. Healthcare resource use included inpatient, outpatient, and emergency room visits. A multivariate regression model assessed the relationship between adherence and one-year healthcare resource use, controlling for demographics, comorbidities, and baseline resource use. Unit healthcare costs were obtained from the 2005 Medical Expenditure Panel Survey, adjusted to 2008 dollars.

RESULTS

Based on a sample of 55,076 COPD patients, adherence was strongly correlated with dosing frequency. PDC was 43.3%, 37.0%, 30.2% and 23.0% for QD, BID, TID, and QID patient cohorts, respectively. Regression analysis showed that one-year adherence was correlated with healthcare resource utilization. For 1000 COPD patients, a 5% point increase in PDC reduced the annual number of inpatient visits (-2.5%) and emergency room visits (-1.8%) and slightly increased outpatient visits (+.2%); the net reduction in annual cost was approximately $300,000.

CONCLUSION

COPD patients who initiated treatment with once-daily dosing had significantly higher adherence than other daily dosing frequencies. Better treatment adherence was found to yield reductions in healthcare resource utilization and cost.

Health care utilization history, GOLD guidelines, and respiratory medication prescriptions in patients with COPD

BACKGROUND

The relationship between prior health care utilization and respiratory medication prescriptions in an unselected population of patients with COPD is not known.

METHODS

We determined the prescribed respiratory medications and respiratory and nonrespiratory health care encounters in 523 Veterans with COPD at the Cincinnati Veterans Affairs Medical Center between 2000 and 2005. Prescribed treatments were compared with the GOLD guidelines and each patient was classified as receiving less medications than recommended in the guidelines (<G), medications according to the guidelines (=G), or more medications than recommended (>G).

RESULTS

Respiratory medications were <G for 54%, =G in 33%, and >G for 14% of the patients studied. For GOLD stages 1 and 2, <G patients had the fewest and >G patients the most prior respiratory encounters during a 12 month period (0.31 +/- 0.073 (0.21, 0.47), 0.75 +/- 0.5 (0.37, 1.5), 1.1 +/- 0.27 (0.74, 1.6) visits/person/year, <G, =G, >G, respectively, mean + standard error of mean (SEM) (95% confidence limits) 2 degrees of freedom (df) ANOVA P < 0.001 for prescription effect). For GOLD stages 3 and 4, <G was associated with significantly fewer prior respiratory visits than was =G (0.78 +/- 0.11 (0.6, 1.0) and 2.4 +/- 0.47 (1.9, 3.1) visits/person/year, respectively, P < 0.001). There were no differences in nonrespiratory health care visits for GOLD stages 1 and 2 by prescription level (3.1 +/- 0.24 (2.6, 3.5), 3.1 +/- 0.46 (2.1, 4.6) and 4.1 +/- 0.55 (3.3, 5.1) visits/person/year, <G, =G, >G respectively, 2 df ANOVA P = 0.096) or for GOLD stages 3 and 4 (3.6 +/- 0.25 (3.2, 4.1) and 4.0 +/- 0.44 (3.3, 4.9) visits/person/year, <G and =G, respectively, P = 0.36).

CONCLUSIONS

Respiratory medications prescribed for an unselected population with a broad range of COPD severity complied poorly with the GOLD pharmacologic treatment guidelines but correlated with the number of prior respiratory health care visits.

COPD Management in Primary Care: An Observational, Community Pharmacy–Based Study

Background:

Chronic obstructive pulmonary disease (COPD) is a prevalent disease that is frequently treated in primary care. However, data regarding the primary care management of COPD are scarce. Such observational data are necessary to detect problem areas and to develop targeted interventions for improvement of COPD management.

Objective:

To provide a detailed description of (1) drug therapy, (2) drug adherence, (3) inhalation technique, and (4) health status of patients with COPD recruited via community pharmacies.

Methods:

A cross-sectional, observational study was conducted in 93 pharmacies in Belgium. Participants (N = 555) completed a questionnaire collecting information on personal characteristics, smoking history, influenza vaccination, COPD medication, and adverse effects. Adherence to COPD maintenance medication was analyzed 1 year retrospectively through prescription refill rates. Inhalation technique was scored using a checklist. Health status was evaluated with the St. George's Respiratory Questionnaire, the Clinical COPD Questionnaire, and the Modified Medical Research Council dyspnea scale.

Results:

The mean age of the patients was 68.6 years; 73.7% were men and 37.2% were current smokers. The influenza vaccination status was significantly lower in patients aged less than 65 years (65.7%) than in patients aged 65 years or more (86.2%) (p < 0.001). Fixed combinations of inhaled corticosteroids and long-acting β2-agonists were the most frequently used COPD medications (75.4%). About 48% of patients were underadherent (<80% adherence), 47% were adherent (80–120% adherence) and 5% were overadherent (>120% adherence). Predictors for underadherence were age and number of drugs. Twenty-one percent of patients made major inhalation technique errors with rescue medication; these were all errors in handling pressurized metered-dose inhalers (pMDIs).

Conclusions:

This observational study on COPD management in primary care highlights 4 main aspects that could be improved: (1) drug adherence, (2) inhalation technique with pMDIs, (3) influenza vaccination in COPD patients younger than 65 years, and (4) smoking cessation.

Medication adherence issues in patients treated for COPD

Although medical treatment of COPD has advanced, nonadherence to medication regimens poses a significant barrier to optimal management. Underuse, overuse, and improper use continue to be the most common causes of poor adherence to therapy. An average of 40%–60% of patients with COPD adheres to the prescribed regimen and only 1 out of 10 patients with a metered dose inhaler performs all essential steps correctly. Adherence to therapy is multifactorial and involves both the patient and the primary care provider. The effect of patient instruction on inhaler adherence and rescue medication utilization in patients with COPD does not seem to parallel the good results reported in patients with asthma. While use of a combined inhaler may facilitate adherence to medications and improve efficacy, pharmacoeconomic factors may influence patient’s selection of both the device and the regimen. Patient’s health beliefs, experiences, and behaviors play a significant role in adherence to pharmacological therapy. This manuscript reviews important aspects associated with medication adherence in patients with COPD and identifies some predictors of poor adherence.

[Treatment of chronic obstructive pulmonary disease in 5 Latin American cities: the PLATINO study]

OBJECTIVE

PLATINO project is a population-based study designed to determine the prevalence of chronic obstructive pulmonary disease (COPD) in São Paulo, Brazil; Mexico City, Mexico; Montevideo, Uruguay; Santiago de Chile, Chile; and Caracas, Venezuela. The objective of this portion of PLATINO was to describe preventive and pharmacological treatment of COPD patients and factors associated with such treatment.

PATIENTS AND METHODS

Eligible subjects completed a questionnaire and underwent postbronchodilator spirometry.

RESULTS

Of the total of 5529 individuals who answered items referring to treatment, 758 had COPD (ratio of postbronchodilator forced expiratory volume in 1 second to forced vital capacity of <0.7), and 86 of them had been previously diagnosed by a physician. Among all COPD patients, only half of smokers or former smokers had been advised to quit and 24.7% had received some type of respiratory medication. Only 13.5% had used inhaled corticosteroids, and those were the patients with the most severe disease. In the group of patients who had a previous medical diagnosis of COPD, 69% of the smokers or former smokers had been advised to quit by a physician and 75.6% had received respiratory medication in the preceding year: 43% reported having used inhaled medication and 36% had used bronchodilators. Rates of vaccination against influenza and the use of mucolytic drugs and inhalers varied from one health care facility to another. All drug prescriptions were based on previous spirometry.

CONCLUSIONS

Spirometry emerged not only as a diagnostic tool, but also as a factor associated with treatment, against a background of uneven use of available health care resources in these 5 Latin American cities.

Bronchodilators in COPD: impact of beta-agonists and anticholinergics on severe exacerbations and mortality

This review summarizes the long-term clinical outcomes associated with β-agonist and anticholinergic bronchodilator use in patients with chronic obstructive pulmonary disease (COPD). Pooled data from randomized placebo-controlled trials of at least three months duration were used to evaluate the risk for COPD hospitalizations, respiratory mortality, and total mortality. The results show that anticholinergic use is associated with a 30% reduction in COPD hospitalizations, a 70% reduction in respiratory mortality, and without a significant effect on total mortality. In contrast, β-agonist use had no effect on COPD hospitalizations and was associated with a two-fold increased risk for respiratory death compared with placebo. When the two bronchodilators were directly compared with each other, β-agonists were associated with a two-fold increased risk for COPD hospitalization and a five-fold increased risk for total mortality compared with anticholinergics. When β-agonists were added to either anticholinergic use or inhaled corticosteroid use alone, there was no significant improvement in any long-term clinical outcome. These results indicate that anticholinergics should be the bronchodilator of choice in COPD, while β-agonists may be associated with poorer disease control.

Clinical efficacy of the transdermal tulobuterol patch in patients with chronic obstructive pulmonary disease: a comparison with slow-release theophylline

BACKGROUND

There is insufficient evidence for the efficacy of a transdermal tulobuterol patch (TP), although combination therapy with bronchodilators is recommended for chronic obstructive pulmonary disease (COPD).

OBJECTIVE

A randomized, controlled crossover study was conducted to evaluate the clinical efficacy and safety of the TP in 16 patients with COPD. Slow-release theophylline was used as a control drug.

METHODS

Following a 2-week run-in period, patients were randomly allocated to two groups by the envelope method; they then received the TP and theophylline for 4 weeks each by the crossover method. Pulmonary function tests, peripheral blood examination, and electrocardiography were performed before and after each treatment period. Patients recorded in diaries their symptom scores, numbers of administrations of inhaled beta(2) agonists, and presence/absence of adverse reactions.

RESULTS

Patients receiving TP exhibited significant improvement in the number and ease of sputum expectoration and in cough frequency score and wheezing severity score compared with baseline (p<0.05); the corresponding improvement in patients receiving theophylline was non-significant. Assessment of quality of life by the St. George's Hospital Respiratory Questionnaire revealed that treatment with TP was associated with significant improvement in symptoms, impact, and total scores compared with baseline (p<0.05); theophylline gave only a non-significant improvement in total score. Neither drug caused significant changes in the results of physiological examinations or in pulse or blood pressure. There was no difference in safety between the treatments.

CONCLUSION

Treatment of COPD patients with TP is more effective than with theophylline.

Fast onset of effect of budesonide/formoterol versus salmeterol/fluticasone and salbutamol in patients with chronic obstructive pulmonary disease and reversible airway obstruction

BACKGROUND AND OBJECTIVES

Data on the onset of action of COPD medications are lacking. This study compared the onset of bronchodilation following different inhaled therapies in patients with moderate-to-severe COPD and reversible airway obstruction.

METHODS

In this double-blind, double-dummy, crossover study, 90 patients (aged >or=40 years; FEV(1) 30-70% predicted) were randomized to a single dose (two inhalations) of budesonide/formoterol 160/4.5 microg, salmeterol/fluticasone 25/250 microg, salbutamol 100 microg or placebo (via pressurized metered-dose inhalers) on four visits. The primary end-point was change in FEV(1) 5 min after drug inhalation; secondary end-points included inspiratory capacity (IC) and perception of onset of effect.

RESULTS

Budesonide/formoterol significantly improved FEV(1) at 5 min compared with placebo (P < 0.0001) and salmeterol/fluticasone (P = 0.0001). Significant differences were first observed at 3 min. Onset of effect was similar with budesonide/formoterol and salbutamol. Improvements in FEV(1) following active treatments were superior to placebo after 180 min (all P < 0.0001); both combinations were better than salbutamol at maintaining FEV(1) improvements (P <or= 0.0001) at 180 min. Active treatments improved IC at 15 and 185 min compared with placebo (P < 0.0001). Maximal IC was greater with budesonide/formoterol than salmeterol/fluticasone (P = 0.0184) at 65 min. Patients reported a positive response to the perceptions of the onset of effect question shortly after receiving active treatments (median time to onset 5 min for active treatments vs 20 min for placebo), with no significant difference between active treatments.

CONCLUSION

Budesonide/formoterol has an onset of bronchodilatory effect in patients with COPD and reversible airway obstruction that is faster than salmeterol/fluticasone and similar to salbutamol.

National survey of guideline-compliant COPD management among pneumologists and primary care physicians

The aim of this survey was to investigate guideline-compliant COPD management among pneumologists and primary care physicians (PCPs). A multiple-choice questionnaire was sent out to 1836 PCPs and 863 pneumologists in Germany. The questions focused on the key aspects of current national and international COPD guidelines. Four hundred eighty-six PCPs and 359 pneumologists participated in the study. It was found that pneumologists held the GOLD guideline in high regard (60.4%), while PCPs tended to follow the German National COPD guideline (66.5%). Differences were also found with regard to diagnosis and classification of COPD on the basis of spirometric and clinical criteria. The current GOLD classification of moderate and severe COPD was used by 36.2% and 23.4% of the pneumologists, respectively, and by 32.1% and 20.2% of the PCPs. Although PCPs and pneumologists endorsed educational measures to help patients quit smoking, implementation was still inadequate. The two most important therapeutic goals were to improve quality of life and prevent exacerbations. Except for the criteria for the use of steroids and the implementation of pulmonary rehabilitation measures, treatment of COPD based on severity class was largely in compliance with guidelines. However, appreciably more PCPs than pneumologists incorrectly assessed the evidence-based clinical benefits of various therapeutic measures. The study shows that, despite the popularity of COPD guidelines, deficits exist among pneumologists and PCPs with respect to diagnosis and treatment of COPD and practical implementation of educational measures. These deficiencies in guideline conformity might be best addressed through targeted continuing-education measures.

Systematic review of clinical outcomes in chronic obstructive pulmonary disease: beta-agonist use compared with anticholinergics and inhaled corticosteroids

Much controversy surrounds the use of beta-agonists in obstructive lung disease. Regular beta2- agonist use in asthma results in tolerance to its effects and an increase in asthma-related deaths. Less is known about clinical outcomes in chronic obstructive pulmonary disease (COPD). This systematic review and meta-analysis evaluates the long-term effect of beta2-agonist use on severe exacerbations requiring hospitalization or trial withdrawal, respiratory deaths, and total mortality in patients with COPD. Results for beta2-agonists are compared with results for anticholinergics and inhaled corticosteroids. Pooled results from randomized controlled trials show that anticholinergics, such as tiotropium and ipratropium, significantly reduce severe exacerbations and respiratory deaths compared with placebo. Conversely, beta2-agonists increase respiratory deaths, probably because of tolerance that develops to their bronchodilator and bronchoprotective effects. Anticholinergics significantly reduce exacerbations and total mortality compared with beta-agonists. The combination of the two bronchodilators is not more effective than anticholinergics alone in improving long-term clinical outcomes. Inhaled corticosteroids significantly reduce severe exacerbations and the decline in lung function over time, without affecting mortality. In conclusion, inhaled anticholinergic bronchodilators and corticosteroids should be used to improve long-term clinical outcomes in patients with COPD. beta-Agonists increase respiratory deaths in COPD, possibly as a result of poorer disease control.

The quality of obstructive lung disease care for adults in the United States as measured by adherence to recommended processes

BACKGROUND

The extent to which patients with obstructive lung disease receive recommended processes of care is largely unknown. We assessed the quality of care delivered to a national sample of the US population.

METHODS

We extracted medical records for 2 prior years from consenting participants in a random telephone survey in 12 communities and measured the quality of care provided with 45 explicit, process-based quality indicators for asthma and COPD developed using the modified Delphi expert panel methodology. Multivariate logistic regression evaluated effects of patient demographics, insurance, and other characteristics on the quality of health care.

RESULTS

We identified 2,394 care events among 260 asthma participants and 1,664 events among 169 COPD participants. Overall, participants received 55.2% of recommended care for obstructive lung disease. Asthma patients received 53.5% of recommended care; routine management was better (66.9%) than exacerbation care (47.8%). COPD patients received 58.0% of recommended care but received better exacerbation care (60.4%) than routine care (46.1%). Variation was seen in mode of care with considerable deficits in documenting recommended aspects of medical history (41.4%) and use of diagnostic studies (40.1%). Modeling demonstrated modest variation between racial groups, geographic areas, insurance types, and other characteristics.

CONCLUSIONS

Americans with obstructive lung disease received only 55% of recommended care. The deficits and variability in the quality of care for obstructive lung disease present ample opportunity for quality improvement. Future endeavors should assess reasons for low adherence to recommended processes of care and assess barriers in delivery of care.

From Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines to current clinical practice : an overview of the pharmacological therapy of stable chronic obstructive pulmonary disorder

BACKGROUND

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines have been promulgated to improve the management of chronic obstructive pulmonary disorder (COPD).

OBJECTIVE

To evaluate the extent to which the current therapeutic approach to COPD conforms to GOLD guidelines.

METHODS

This was a multicentre observational study of elderly COPD patients enrolled for acute care in general medicine or geriatric wards in tertiary hospitals in Italy in April 2002. Our series consisted of 471 patients >64 years of age consecutively admitted for acute exacerbations of COPD to wards participating in the study. Data describing drugs used prior to exacerbation and prescribed at discharge were collected using a standardised protocol. Changes in prescription at discharge were then compared with home therapy. Demographic variables and indices of COPD severity and co-morbidity were tested as potential correlates for the main outcome measure 'variant prescription', i.e. prescription of a drug considered as a third-line treatment (e.g. methylxanthines) or not recommended (e.g. mucolytics) by GOLD guidelines. The correlation was assessed first by univariate analysis and then by logistic regression analysis.

RESULTS

At discharge, prescription of short-acting beta(2)-adrenoceptor agonists had decreased from 26.3% to 14.0%. Conversely, increases in prescription of long-actingbeta(2)-adrenoceptor agonists (from 43.1% to 68.4%), inhaled corticosteroids (50.7% to 69.6%) and anticholinergics (17.2% to 22.3%) were seen. The rate of use of methylxanthines was 49.7% before admission and 44.8% at discharge, with previous use being the main correlate of discharge prescription for this class of drugs (odds ratio [OR] = 4.35; 95% CI 2.88, 6.54). The rate of use of mucolytics was 26.3% before admission and 26.8% at discharge, with use of mucolytics prior to admission being the only correlate of discharge prescription (OR = 4.10; 95% CI 2.47, 6.82).

CONCLUSIONS

Hospitalisation resulted in increased adherence to GOLD guidelines in patients with COPD, but the rate of use of anticholinergics was distinctly low and that of methylxanthines and mucolytics surprisingly high. A carry-over effect (i.e. of therapy prescribed by general practitioners on that prescribed by hospital-based physicians) likely accounts for most of the 'variant prescriptions' seen at discharge from the acute care hospital.

Meta-analysis: anticholinergics, but not beta-agonists, reduce severe exacerbations and respiratory mortality in COPD

BACKGROUND

Anticholinergics and beta2-agonists have generally been considered equivalent choices for bronchodilation in chronic obstructive pulmonary disease (COPD).

OBJECTIVE

To assess the safety and efficacy of anticholinergics and beta2-agonists in COPD.

DESIGN

We comprehensively searched electronic databases from 1966 to December 2005, clinical trial websites, and references from selected reviews. We included randomized controlled trials of at least 3 months duration that evaluated anticholinergic or beta2-agonist use compared with placebo or each other in patients with COPD.

MEASUREMENTS

We evaluated the relative risk (RR) of exacerbations requiring withdrawal from the trial, severe exacerbations requiring hospitalization, and deaths attributed to a lower respiratory event.

RESULTS

Pooled results from 22 trials with 15,276 participants found that anticholinergic use significantly reduced severe exacerbations (RR 0.67, confidence interval [CI] 0.53 to 0.86) and respiratory deaths (RR 0.27, CI 0.09 to 0.81) compared with placebo. Beta2-agonist use did not affect severe exacerbations (RR 1.08, CI 0.61 to 1.95) but resulted in a significantly increased rate of respiratory deaths (RR 2.47, CI 1.12 to 5.45) compared with placebo. There was a 2-fold increased risk for severe exacerbations associated with beta2-agonists compared with anticholinergics (RR 1.95, CI 1.39 to 2.93). The addition of beta2-agonist to anticholinergic use did not improve any clinical outcomes.

CONCLUSION

Inhaled anticholinergics significantly reduced severe exacerbations and respiratory deaths in patients with COPD, while beta2-agonists were associated with an increased risk for respiratory deaths. This suggests that anticholinergics should be the bronchodilator of choice in patients with COPD, and beta2-agonists may be associated with worsening of disease control.

Efficacy of Nebulized Flunisolide Combined with Salbutamol and Ipratropium Bromide in Stable Patients with Moderate-to-Severe Chronic Obstructive Pulmonary Disease

BACKGROUND

The efficacy of nebulized corticosteroids in the prevention of exacerbation of chronic obstructive pulmonary disease (COPD) has been poorly studied.

OBJECTIVE

To evaluate the efficacy and tolerability of nebulized flunisolide (1 mg) + salbutamol/ipratropium bromide (1,875/375 microg) b.i.d. in comparison with placebo + salbutamol/ipratropium bromide.

METHODS

This was a randomized, parallel-group, double-blind study on 114 patients with COPD of moderate-to-severe degree. The main outcome was the frequency of severe exacerbations over a 6-month period. Before and after treatment, respiratory symptoms, forced expiratory volume in 1 s (FEV(1)), shuttle walking test distance and St. George's Respiratory Questionnaire scores were evaluated.

RESULTS

The total number of exacerbations was slightly lower in the flunisolide group compared to the placebo group (19 vs. 34, p = 0.054); the number of patients experiencing at least one exacerbation during the study was also decreased (16 vs. 26, p = 0.059). In particular, type 3 Anthonisens's exacerbations were significantly reduced by flunisolide (p = 0.044). In the placebo group, scores were higher than in the flunisolide group but nonsignificant for dyspnea, cough, sputum amount and purulence. FEV(1) was significantly increased compared to baseline in both groups, and the area under the FEV(1)-time curve during the 6-month period was significantly greater in the flunisolide group (5.2 +/- 10.6 vs. 2.1 +/- 5.0, flunisolide vs. placebo, respectively; p = 0.047). For shuttle walking test distance and scores of the St. George's Respiratory Questionnaire, no significant difference between the baseline evaluation and the end of the study was observed in both groups.

CONCLUSIONS

Nebulized flunisolide is a good alternative to other inhaled corticosteroids when added to nebulized salbutamol/ipratropium bromide in the long-term treatment of moderate-to-severe COPD patients.

An appraisal of pharmacoeconomic evidence of maintenance therapy for COPD

COPD is projected to be the third-leading cause of death by the year 2020. Pharmacotherapy for COPD is palliative at best, having no impact on slowing the progression of the disease. The introduction of newer therapies such as long-acting forms of bronchodilator and anticholinergic agents, together with the inclusion of inhaled corticosteroids (ICSs) in the recent Global Initiative for COPD therapeutic algorithm, have expanded the pharmacotherapy options for the treatment of COPD. This article provides a methodologic critique of the available pharmacoeconomic evidence on drug therapy for stable COPD in an effort to complement treatment guidelines and to identify any need for future pharmacoeconomic research. Relevant search strategies revealed a total of 28 economic evaluations of which 7 satisfied the study inclusion criteria. The Drummond 10-point checklist was used for the methodological critique of the economic evaluations. Five of seven pharmacoeconomic studies were conducted alongside a randomized controlled trial, and six of seven were cost-effectiveness analyses. Of the bronchodilators, the long-acting anticholinergic agent tiotropium is considered to be cost-effective relative to ipratropium. No conclusive information could be reached for the cost-effectiveness of long-acting beta-agonists. A Markov analysis showed ICSs to be cost-effective for patients with moderate-to-severe COPD relative to standard care. However, assumptions of the model may bias this conclusion, and additional studies are warranted, especially compared to other treatments. The authors suggest that additional pharmacoeconomic studies be conducted to assess the cost-effectiveness of long-acting beta-agonists and ICSs, between classes of bronchodilators, and between various combination therapies.

The puzzle of overactive bladder: controversies, inconsistencies, and insights

Overactive bladder (OAB) affects millions of individuals and may severely impair the quality of life of those affected. The contribution of human behavior to manifestations of this symptom complex remains poorly understood. Continued evolution of our understanding of the pathophysiology of OAB has identified contributory mechanisms, which in turn may open new therapeutic avenues. Recent improvements in drug delivery systems represent advances in the management of OAB. However, more complete symptom control with greater tolerability is desirable; this awaits the development of agents specific for newly emerging and as yet unidentified pathophysiologic pathways. Importantly, as understanding of outcomes assessment in OAB matures, refined assessments of disease severity, response to intervention, and patient preference should be possible.

[Effectiveness and efficiency of a specialized unit in the care of patients with chronic obstructive pulmonary disease and respiratory insufficiency]

OBJECTIVE

In the absence of a clear health care model for the management of patients with chronic obstructive pulmonary disease and chronic respiratory insufficiency, we evaluated the effectiveness and efficiency of a specialized outpatient unit for these patients managed by the hospital s respiratory medicine department.

PATIENTS AND METHODS

This was a 1-year prospective study of a group of patients for whom historical control data were available. The mean (SD) descriptive data for the 124 patients (105 men) were as follows: age, 69 (7) years; forced vital capacity, 64.6% (16.1%); forced expiratory volume in the first second (FEV1), 35.6% (12.8%); PaO2, 56.6 (8.3) mm Hg; PaCO2, 49.8 (6.7) mm Hg. Forced spirometry and arterial blood gas analysis were performed at 3-monthly visits. Participants completed a quality-of-life questionnaire (Guyatt's Chronic Respiratory Disease Questionnaire) at the beginning and end of the study. The following variables were analyzed: forced spirometry, arterial blood gases, quality of life, number of emergency visits and hospital admissions, mean length of stay in hospital, reduction in the number of inpatient bed-days, mean cost of emergency visits, mean cost of hospital stays for both the Catalan Health Service (CHS) and the hospital, mean total cost per patient for the CHS and the hospital, and aggregate cost for the CHS and the hospital. The results were compared with data for the preceding year taken from the hospital records.

RESULTS

Significant improvement was found in forced vital capacity and PaO2 (which went from 56.6 [8.2] mm Hg to 59.1 [8.9] mm Hg during the prospective part of the study); FEV1 also tended to improve (875 [282] mL as against 912 [321] mL), but this change was not significant (P= .17). A significant reduction was observed in the following variables: PaCO2; hospital admissions, 1.16 (1.15) in the historical control period compared to 0.67 (1.17) during the prospective study; emergency visits, 2.06 (1.9) as against 1.5 (2.1); mean length of stay in hospital, 14.2 (19) compared to 8.1 (16) days; total number of inpatient bed-days (756 inpatient bed-days were saved in the study period); mean cost of emergency visits and hospital stays for both the hospital (2246 euros [3007 euros] in the historical period as against 1297 euros [2639 euros] with the new management system) and for the CHS; and the aggregate cost both for the hospital (40,011 euros in the historical control period as against 6048 euros with the new model) and the CHS (238,513 euros as against 152,312 euros). The quality-of-life score improved, but the change was not significant.

CONCLUSIONS

The change in the health care model used to manage these patients led to an improvement in care (effectiveness) as well as a marked reduction in costs (greater efficiency) for both the funding entity (CHS) and for the care provider (the hospital). No change was observed in the quality of life as reported by the patients.

Barriers to success for an evidence-based guideline for chronic obstructive pulmonary disease

OBJECTIVES

To evaluate 1) barriers to clinical guideline use and 2) the relationship between guideline use and inpatient outcomes in chronic obstructive pulmonary disease (COPD).

METHODS

1) Four focus groups of specific health professions (n = 30), from three metropolitan hospitals, and interview of 99 medical officers (MOs), linked to 349 admissions, both guided by behavioural modelling theory; 2) association between guideline use and patient outcomes (length of hospital stay > or = 14 days, and readmission within 28 or 90 days) was evaluated in a cohort of 405 COPD patients.

RESULTS

1) In focus groups, nurses and allied health professionals emphasized facilitation issues including paperwork duplication and time limitations as barriers, but considered improved patient care outcomes as the major guideline use determinant. There were similar findings in junior MOs (nonconsultants) by both focus group and interview, with the addition of a need for a sense of ownership. Senior MOs (consultants) greatly emphasized sense of ownership. Barriers to guideline use varied between types of units. Behavioural modelling explained 49% of the variation in intention to use the guideline for MOs. For nonconsultants, habit and intention were significantly associated with extent of guideline use. 2) Patient outcomes: guideline use was not associated with length of stay or readmission.

CONCLUSIONS

1) Guideline implementation should address issues relevant to different health professions, units and seniority of profession. 2) Guideline use was not associated with reductions in readmission or length of stay.