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

Management of Refractory Chronic Obstructive Pulmonary Disease: A Review

Chronic obstructive pulmonary disease (COPD) is a common condition with an estimated prevalence of 12% in adults over the age of 30 years worldwide. COPD is a leading cause of morbidity and mortality globally, with a substantial economic and social burden. There are an estimated 3 million deaths annually due to COPD. However, most of the patients with COPD respond to routine interventions like bronchodilator therapy, assessing supplemental oxygen needs, smoking cessation, vaccinations, and pulmonary rehabilitation. There is a significant number of patients who unfortunately progress to have persistent symptoms despite these interventions. Refractory COPD is not yet formally defined. Patients with severe persistent symptoms or exacerbations despite appropriate care can be considered to have refractory COPD. Managing refractory COPD needs a multidimensional approach. In this review article, we will discuss essential interventions like ensuring adequate inhaler techniques, exploring the need for non-invasive ventilatory support, use of chronic antibiotics and phosphodiesterase inhibitors to advanced therapies like bronchoscopic lung volume reduction surgery, and the upcoming role of anti-IL5 agents in managing patients with refractory COPD. We will also discuss non-pharmacologic interventions like psycho-social support and nutritional support. We will conclude by discussing the palliative care aspect of managing patients with refractory COPD. Through this review article, we aim to better the approach to managing patients with refractory COPD and discuss new upcoming therapies.

Inhaler Adherence in COPD: A Crucial Step Towards the Correct Treatment

COPD is a typical example of chronic disease. As such, treatment adherence tends to be as low as between 30% and 50%, with specific issues in COPD due to the use of inhaled therapies. Decreased adherence in COPD is associated with worse outcomes, with increased risk for exacerbations and long-term mortality. Factors that impact adherence are multiple, some related to patient, some related to clinicians and finally some related to healthcare system. Among clinician factors, prescription of simplified treatment regimens delivered by an inhaler adapted to the patient's characteristics is crucial. Although it has been observed a huge improvement in the design and usability of inhaler devices for COPD in the last two centuries, there is still a clear gap in this field. Smart inhalers as well as simplified treatment regimens could improve adherence and therefore improve long-term outcomes in COPD.

Methods to assess COPD medications adherence in healthcare databases: a systematic review

BACKGROUND

The Global Initiative for Chronic Obstructive Lung Disease 2023 report recommends medication adherence assessment in COPD as an action item. Healthcare databases provide opportunities for objective assessments; however, multiple methods exist. We aimed to systematically review the literature to describe existing methods to assess adherence in COPD in healthcare databases and to evaluate the reporting of influencing variables.

METHOD

We searched MEDLINE, Web of Science and Embase for peer-reviewed articles evaluating adherence to COPD medication in electronic databases, written in English, published up to 11 October 2022 (PROSPERO identifier CRD42022363449). Two reviewers independently conducted screening for inclusion and performed data extraction. Methods to assess initiation (dispensing of medication after prescribing), implementation (extent of use over a specific time period) and/or persistence (time from initiation to discontinuation) were listed descriptively. Each included study was evaluated for reporting variables with an impact on adherence assessment: inpatient stays, drug substitution, dose switching and early refills.

RESULTS

160 studies were included, of which four assessed initiation, 135 implementation and 45 persistence. Overall, one method was used to measure initiation, 43 methods for implementation and seven methods for persistence. Most of the included implementation studies reported medication possession ratio, proportion of days covered and/or an alteration of these methods. Only 11% of the included studies mentioned the potential impact of the evaluated variables.

CONCLUSION

Variations in adherence assessment methods are common. Attention to transparency, reporting of variables with an impact on adherence assessment and rationale for choosing an adherence cut-off or treatment gap is recommended.

Omega-3 Polyunsaturated Fatty Acids in Managing Comorbid Mood Disorders in Chronic Obstructive Pulmonary Disease (COPD): A Review

Chronic obstructive pulmonary disease (COPD) is the third-leading cause of mortality globally, significantly affecting people over 40 years old. COPD is often comorbid with mood disorders; however, they are frequently neglected or undiagnosed in COPD management, thus resulting in unintended treatment outcomes and higher mortality associated with the disease. Although the exact link between COPD and mood disorders remains to be ascertained, there is a broader opinion that inflammatory reactions in the lungs, blood, and inflammation-induced changes in the brain could orchestrate the onset of mood disorders in COPD. Although the current management of mood disorders such as depression in COPD involves using antidepressants, their use has been limited due to tolerability issues. On the other hand, as omega-3 polyunsaturated fatty acids (n-3 PUFAs) play a vital role in regulating inflammatory responses, they could be promising alternatives in managing mood disorders in COPD. This review discusses comorbid mood disorders in COPD as well as their influence on the progression and management of COPD. The underlying mechanisms of comorbid mood disorders in COPD will also be discussed, along with the potential role of n-3 PUFAs in managing these conditions.

Medication Adherence in Medicare-Enrolled Older Adults with Chronic Obstructive Pulmonary Disease before and during the COVID-19 Pandemic

Medication adherence to controller inhalers was unknown in older Medicare patients with chronic obstructive pulmonary disease (COPD) before and during the pandemic. This study evaluated changes in medication adherence to controller medications and factors associated with high adherence. This retrospective cohort study included older Medicare patients with COPD. The proportion of days covered (PDC) reflected changes in medication adherence from January to July in 2019 and in 2020. Paired t-test evaluated changes in adherence. Logistic regression determined the association of patient characteristics with high adherence (PDC ≥ 80%). Mean adherence decreased (p < 0.001) for long-acting beta-agonists, long-acting muscarinic antagonists, and inhaled corticosteroids in 2020. The percentage of patients with high adherence dropped from 74.4% to 58.1% (p < 0.001). The number of controllers, having ≥3 albuterol fills, and a 90-day supply were associated with high adherence in 2019 and 2020 (p < 0.001). The COVID-19 pandemic may negatively impact medication adherence. Patients with evidence of more severe diseases and a 90-day supply were more likely to adhere to therapy. Healthcare professionals should prioritize prescribing 90-day supplies of medications and monitor drug-related problems as components of pharmacovigilance to enhance adherence to therapies and the desired clinical outcomes among patients with COPD.

Efficacy and safety of vortioxetine in treatment of patients with major depressive disorder and common co-morbid physical illness

BACKGROUND

The multimodal antidepressant vortioxetine is effective in reducing somatic symptoms in patients with major depressive disorder (MDD), but little is known about its effects in reducing depressive symptoms in patients with common comorbid physical illnesses.

METHODS

This was a pooled analysis of 13 randomized, placebo-controlled trials which evaluated the efficacy (using the Montgomery-Åsberg Depression Rating Scale [MADRS]) and safety of vortioxetine (5-20 mg/day) in adult patients with MDD. We evaluated stable somatic comorbid conditions that were verified by a diagnosis and had sufficient database representation.

RESULTS

Of the 5982 patients included in the database, 963 (16.1%) patients had a diagnosis of cardiovascular disease, 152 (2.5%) had diabetes mellitus and 26 (0.4%) had chronic obstructive pulmonary disorder (COPD). At Week 8, adjusted mean[95%CI] treatment differences (vortioxetine vs. placebo) on MADRS total scores were -2.7[-4.2, -1.3] (p = 0.0002) points for the cardiovascular disease, -4.0[-7.7, -0.4] (p = 0.03) for the diabetes, and -6.2[-21.3, 8.9] (p = 0.36) for the COPD groups. The rate and pattern of adverse events were similar across the sub-groups with comorbidities and was consistent with that expected for vortioxetine treatment.

LIMITATIONS

The primary studies were not designed to investigate the relationship between vortioxetine and comorbidities, nor were the post hoc analyses powered to detect group differences.

CONCLUSIONS

Patients with MDD and comorbid cardiovascular disease or diabetes respond to vortioxetine in a similar way to the broader MDD population. Vortioxetine was generally safe and well tolerated and without unexpected adverse events in these subpopulations, most of whom are taking multiple concomitant medications.

Prediction of treatment nonadherence among older adults with chronic obstructive pulmonary disease using Medicare real-world data

BACKGROUND: Suboptimal maintenance medication (MM) adherence remains a clinical problem among Medicare beneficiaries with chronic obstructive pulmonary disease (COPD). OBJECTIVE: To inform risk-based personalized decision-making, this study sought to develop and validate prediction models of nonadherence to COPD MMs for Medicare beneficiaries. METHODS: This was a retrospective cohort study of beneficiaries aged 65 years and older with COPD and inhaled MMs. Nonadherence (proportion of days covered < 0.8) was measured in 12 months following the first MM fill after COPD diagnosis. Logistic and least absolute shrinkage selector operator regressions were implemented, and area under the receiver operating characteristic curve (AUROC) evaluated model accuracy, as well as positive predictive values and negative predictive values. Our models evaluated different sets of predictors for two cohorts: those with an MM prescription before COPD diagnosis (prevalent users) and those without (new users). RESULTS: Among 16,157 prevalent and 40,279 new users of MMs, 11,271 (69.8%) and 34,009 (84.4%), respectively, were nonadherent. The best-performing logistic models achieved AUROCs of 0.8714 and 0.881, positive predictive values of 0.881 and 0.881, and negative predictive values of 0.559 and 0.578, respectively, for prevalent and new users. The least absolute shrinkage selector operator models had similar accuracy. Models with baseline-only predictors had average performance (AUROC < 0.72). The most important predictors were initial MM adherence, short-acting bronchodilator use, and asthma. CONCLUSIONS: To our knowledge, this study is the first to develop predictive models of nonadherence to COPD MMs. Generated models achieved good discrimination and underlined the importance of early adherence. Well-performed models can be useful for care decision-making and interventions to improve COPD medication adherence after the first critical few months following a treatment episode. DISCLOSURES: All authors declared no conflicts of interest.

Clinical Factors Associated With Nonadherence to Chronic Medications in People With Cognitive Impairment

Objective To study assessed adherence to 11 chronic medications and one medication class with high medical necessity in people with cognitive impairment (CIM) and identified clinical characteristics associated with nonadherence. Design This was a retrospective cohort study. 180-day adherence was calculated as the percent of days covered (PDC). Multi-variable logistic regression modeling was used to identify clinical factors associated with a PDC less than 80% (ie, nonadherence) to one or more studied chronic medication(s). Setting Primary care in an integrated health care delivery system. Patients People with CIM 65 years of age or older who were dispensed five or more chronic medications in one month between March 1, 2019, and October 31, 2019. Results Overall, the 1,109 patients included were older (mean age = 79.8 years of age), female (54.1%), White (78.6%), had a high burden of chronic disease, and 396 (35.7%) were nonadherent to one or more study medication(s). Two medications (tiotropium and venlafaxine) and one medication class (direct oral anticoagulants) had a mean PDC less than 80%. Alzheimer's disease and related dementias (ADRD), chronic pain, chronic obstructive pulmonary disease (COPD), male, nonwhite race, and one or more mental health visits were associated independently with nonadherence. Conclusions Chronic pain, COPD, ADRD, male sex, nonwhite race, and mental health care use were associated with nonadherence. These findings can help guide clinicians as they navigate medication therapy in people with CIM.

Impact of the Coronavirus Disease 2019 Pandemic on Physical and Mental Health of Patients With COPD: Results From a Longitudinal Cohort Study Conducted in the United States (2020-2021)

Background

Patients with chronic obstructive pulmonary disease (COPD) are at higher risk for severe coronavirus disease 2019 (COVID-19). From the pandemic's onset there has been concern regarding effects on health and well-being of high-risk patients.

Methods

This was an ancillary study to the Losartan Effects on Emphysema Progression (LEEP) Trial and was designed to collect descriptive information longitudinally about the health and wellbeing of COPD patients who were enrolled in a clinical trial. Participants were interviewed by telephone about their health status every 2 weeks and their mental health, knowledge, and behaviors every 8 weeks from June 2020 to April 2021. There were no pre-specified hypotheses.

Results

We enrolled 157 of the 220 participants from the parent LEEP trial. Their median age was 69 years, 55% were male, and 82% were White; median forced expiratory volume in 1 second (FEV₁)% predicted was 48%. Nine confirmed COVID-19 infections were reported, 2 resulting in hospitalization. Rates of elevated anxiety or depressive symptoms were 8% and 19% respectively in June 2020 and remained relatively stable during follow-up. By April 2021, 85% of participants said they were "very likely" to receive a vaccine; 91% were vaccinated (≥1 dose) by the end of December 2021.

Conclusion

Our select cohort of moderate to severe COPD patients who were well integrated into a health care network coped well with the COVID-19 pandemic. Few participants were diagnosed with COVID-19, levels of depression and anxiety were stable, most adopted accepted risk reduction behaviors, and did not become socially isolated; most were vaccinated by the end of 2021.

Clinical characteristics and outcomes of polypharmacy in chronic obstructive pulmonary disease patients: A cross-sectional study from Crete, Greece

OBJECTIVES

Polypharmacy and multimorbidity in chronic obstructive pulmonary disease (COPD) are highly prevalent, with potential associations with worse COPD outcomes. The aim of this study was to identify the clinical characteristics and outcomes of polypharmacy, investigate the relationship of polypharmacy with health status and exacerbations and assess the prevalence of inappropriate medication (PIM), risk of adverse drug reactions (ADRs) and drug-to-drug interactions in COPD patients.

METHODS

A total of 245 COPD patients were enrolled from primary care in Crete, Greece. Patients completed a questionnaire and the COPD Assessment Test (CAT). Multimorbidity was defined as having two or more comorbidities and polypharmacy was defined as taking five or more drugs per day.

RESULTS

Most of COPD patients (77.0%) and the majority (83.6%) of elderly (≥65 years) had multimorbidity, while polypharmacy was evident in 55.2% of all patients and 62.4% in elderly. After adjustments for age, gender and pack-years, polypharmacy was associated with CAT ≥ 10, multimorbidity, several cardiometabolic diseases, cancer and depression-anxiety and prostate disorders (all p values > 0.05). PIMs were found in 9.6% of subjects aged ≥65 years and were mainly mental health medication. Due to coadministration of medications, 22.3% of the population were at cumulative risk for falls, 17% for constipation and 12.8% for cardiovascular events. Finally, 15 pairs of drug-to-drug interactions were identified in 11.5% of patients.

CONCLUSION

Our data suggest that polypharmacy is highly prevalent and associated with worse health status and prescription risks in COPD patients. These findings potentially introduce an additional challenge on effective management of these patients.

Disturbances in branched-chain amino acid profile and poor daily functioning in mildly depressed chronic obstructive pulmonary disease patients

BACKGROUND

Depression is one of the most common and untreated comorbidities in chronic obstructive pulmonary disease (COPD), and is associated with poor health outcomes (e.g. increased hospitalization/exacerbation rates). Although metabolic disturbances have been suggested in depressed non-diseased conditions, comprehensive metabolic phenotyping has never been conducted in those with COPD. We examined whether depressed COPD patients have certain clinical/functional features and exhibit a specific amino acid phenotype which may guide the development of targeted (nutritional) therapies.

METHODS

Seventy-eight outpatients with moderate to severe COPD (GOLD II-IV) were stratified based on presence of depression using a validated questionnaire. Lung function, disease history, habitual physical activity and protein intake, body composition, cognitive and physical performance, and quality of life were measured. Comprehensive metabolic flux analysis was conducted by pulse stable amino acid isotope administration. We obtained blood samples to measure postabsorptive kinetics (production and clearance rates) and plasma concentrations of amino acids by LC-MS/MS. Data are expressed as mean [95% CI]. Stats were done by graphpad Prism 9.1.0. ɑ < 0.05.

RESULTS

The COPD depressed (CD, n = 27) patients on average had mild depression, were obese (BMI: 31.7 [28.4, 34.9] kg/m2), and were characterized by shorter 6-min walk distance (P = 0.055), physical inactivity (P = 0.03), and poor quality of life (P = 0.01) compared to the non-depressed COPD (CN, n = 51) group. Lung function, disease history, body composition, cognitive performance, and daily protein intake were not different between the groups. In the CD group, plasma branched chain amino acid concentration (BCAA) was lower (P = 0.02), whereas leucine (P = 0.01) and phenylalanine (P = 0.003) clearance rates were higher. Reduced values were found for tyrosine plasma concentration (P = 0.005) even after adjustment for the large neutral amino acid concentration (= sum BCAA, tyrosine, phenylalanine and tryptophan) as a marker of dopamine synthesis (P = 0.048).

CONCLUSION

Mild depression in COPD is associated with poor daily performance and quality of life, and a set of metabolic changes in depressed COPD that include perturbation of large neutral amino acids, specifically the BCAAs. Trial registration clinicaltrials.gov: NCT01787682, 11 February 2013-Retrospectively registered; NCT02770092, 12 May 2016-Retrospectively registered; NCT02780219, 23 May 2016-Retrospectively registered; NCT03796455, 8 January 2019-Retrospectively registered.

Prevalence and Newly Diagnosed Rates of Multimorbidity in Older Medicare Beneficiaries with COPD

Few studies have quantified the multimorbidity burden in older adults with chronic obstructive pulmonary disease (COPD) using large and generalizable data. Such evidence is essential to inform evidence-based research, clinical care, and resource allocation. This retrospective cohort study used a nationally representative sample of Medicare beneficiaries aged 65 years or older with COPD and 1:1 matched (on age, sex, and race) non-COPD beneficiaries to: (1) quantify the prevalence of multimorbidity at COPD onset and one-year later; (2) quantify the rates [per 100 person-years (PY)] of newly diagnosed multimorbidity during in the year prior to and in the year following COPD onset; and (3) compare multimorbidity prevalence in beneficiaries with and without COPD. Among 739,118 eligible beneficiaries with and without COPD, the average number of multimorbidity was 10.0 (SD = 4.7) and 1.0 (SD = 3.3), respectively. The most prevalent multimorbidity at COPD onset and at one-year after, respectively, were hypertension (70.8% and 80.2%), hyperlipidemia (52.2% and 64.8%), anemia (42.1% and 52.0%), arthritis (39.8% and 47.7%), and congestive heart failure (CHF) (31.3% and 38.8%). Conditions with the highest newly diagnosed rates before and following COPD onset, respectively, included hypertension (39.8 and 32.3 per 100 PY), hyperlipidemia (22.8 and 27.6), anemia (17.8 and 20.3), CHF (16.2 and 13.2), and arthritis (12.9 and 13.2). COPD was significantly associated with increased odds of all measured conditions relative to non-COPD controls. This study updates existing literature with more current, generalizable findings of the substantial multimorbidity burden in medically complex older adults with COPD-necessary to inform patient-centered, multidimensional care.Supplemental data for this article is available online at https://doi.org/10.1080/15412555.2021.1968815 .

Prevalence and predictors of medication non-adherence among people living with multimorbidity: a systematic review and meta-analysis

OBJECTIVES

This systematic review aimed to describe medication non-adherence among people living with multimorbidity according to the current literature, and synthesise predictors of non-adherence in this population.

METHODS

A systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses. PubMed, EMBASE, CINAHL and PsycINFO were searched for relevant articles published in English language between January 2009 and April 2019. Quantitative studies reporting medication non-adherence and/or predictors of non-adherence among people with two or more chronic conditions were included in the review. A meta-analysis was conducted with a subgroup of studies that used an inclusive definition of multimorbidity to recruit participants, rather than seeking people with specific conditions. Remaining studies reporting prevalence and predictors of non-adherence were narratively synthesised.

RESULTS

The database search produced 10 998 records and a further 75 were identified through other sources. Following full-text screening, 178 studies were included in the review. The range of reported non-adherence differed by measurement method, at 76.5% for self-report, 69.4% for pharmacy data, and 44.1% for electronic monitoring. A meta-analysis was conducted with eight studies (n=8949) that used an inclusive definition of multimorbidity to recruit participants. The pooled prevalence of non-adherence was 42.6% (95% CI: 34.0 - 51.3%, k=8, I²=97%, p<0.01). The overall range of non-adherence was 7.0%-83.5%. Frequently reported correlates of non-adherence included previous non-adherence and treatment-related beliefs.

CONCLUSIONS

The review identified a heterogeneous literature in terms of conditions studied, and definitions and measures of non-adherence used. Results suggest that future attempts to improve adherence among people with multimorbidity should determine for which conditions individuals require most support. The variable levels of medication non-adherence highlight the need for more attention to be paid by healthcare providers to the impact of multimorbidity on chronic disease self-management.

PROSPERO REGISTRATION NUMBER

CRD42019133849.

The Relationship Between Anxiety, Depression and Treatment Adherence in Chronic Obstructive Pulmonary Disease: A Systematic Review

Background

Almost half of the people with chronic obstructive pulmonary disease (COPD) do not adhere to the prescribed treatments and report anxiety and depression as comorbidities, resulting in higher rates of exacerbations, hospitalizations, and worse clinical outcomes.

Objective

This systematic review provided a synthesis of studies about the relationships between anxiety, depression, and adherence in people affected by COPD.

Methods

English language publications were searched in the PUBMED, SCOPUS, PsycInfo, Web of Science, PsycArticles, and Cochrane Library databases from December 2020 to March 2021, following PRISMA guidelines. The reference lists of eligible studies and other relevant systematic reviews were also searched. Data extraction and critical appraisal were undertaken by two reviewers working independently. The reference lists of eligible studies and other relevant systematic reviews were also searched. Data extraction and critical appraisal were undertaken by two reviewers working independently.

Results

A total of 34 studies (23 quantitative and 2 qualitative studies, 9 reviews) were included. The relationship between depression and treatment adherence was significant and negative. Adherence to both rehabilitation, psychological, and antidepressant pharmacological treatments in depressed patients was linked to a decreased risk of hospitalization. Moreover, depressed patients compliant with an antidepressant were more likely to adherent to COPD maintenance inhalers. On the other hand, the associations between anxiety and adherence were poorly investigated and high heterogeneity characterized the studies, leading to a weak and variable relationship as well as too few interventions.

Conclusion

The systematic review highlights the variability in estimates of the relationship between depression, anxiety, and treatment adherence in COPD. It could be explained by methodological differences across the included studies. This suggests that standardization is critical to improving the precision of the estimates. Recommendations for future research include attention to causal inferences, an exploration of mechanisms to explain the relationships between both anxiety and depression and adherence in COPD, and a comprehensive, systematic approach.

Treatable traits in an English cohort: prevalence and predictors of future decline in lung function and quality of life in COPD

Background

“Treatable traits (TTs)” is a precision medicine approach for facilitating multidimensional assessment of every patient with chronic airway disease, in order to determine the core traits associated with disease outcomes where targeted treatments may be applied.

Objectives

To determine the prevalence of TTs in chronic obstructive pulmonary disease (COPD) and which traits predict future decline in lung function and quality of life (QoL).

Methods

A 4-year longitudinal evaluation was conducted using data from 3726 participants in the English Longitudinal Study of Ageing (ELSA). TTs were identified based on published recommendations. Traits that predicted decline in lung function and QoL were analysed using generalised estimating equations.

Results

Overall, 21 TTs, including pulmonary (n=5), extra-pulmonary (n=13) and behavioural/lifestyle risk-factors (n=3) were identified. In multivariate analyses, the traits of chronic bronchitis (β −0.186, 95% CI −0.290 to −0.082), breathlessness (β −0.093, 95% CI −0.164 to −0.022), underweight (β −0.216, 95% CI −0.373 to −0.058), sarcopenia (β −0.162, 95% CI −0.262 to −0.061) and current smoking (β −0.228, 95% CI −0.304 to −0.153) predicted decline in forced expiratory volume in 1 s (FEV₁). Of the seven traits that predicted decline in QoL, depression (β −7.19, 95% CI −8.81 to −5.57) and poor family and social support (β −5.12, 95% CI −6.65 to −3.59) were the strongest.

Conclusion

The core TTs of COPD associated with a decline in lung function and QoL were identified. Targeting these impactful traits with individualised treatment using a precision medicine approach may improve outcomes in people with COPD.

Targeting the traits of chronic bronchitis, breathlessness, underweight, sarcopenia, depression, smoking, and poor family and social support may significantly improve health outcomes in people with COPDhttps://bit.ly/3cLHIPV

[COPD, anxiety-depression and cognitive disorders: Does inflammation play a major role?]

COPD is a chronic respiratory disease, often associated with extrapulmonary manifestations. Co-morbidities, including anxiety, depression and cognitive impairment, worsen its progression and quality of life. The prevalence of these disorders is high, yet they are often poorly understood and inadequately managed. In the development of psychological disorders, there is accumulated evidence highlighting the major role of systemic inflammation, as well as chronic disease, genetics, the consequences of smoking, hypoxaemia, oxidative stress, and the gut microbiome In addition to traditional treatments such as bronchodilatator medications, respiratory rehabilitation and smoking cessation, systemic inflammation is an interesting therapeutic target, with the use of anti-inflammatory drugs, anti-cytokines, and nutritional interventions.

Effectiveness of a Psychoeducational Group Intervention Carried Out by Nurses for Patients with Depression and Physical Comorbidity in Primary Care: Randomized Clinical Trial

The association between physical illness and depression implies a poorer management of chronic disease and a lower response to antidepressant treatments. Our study evaluates the effectiveness of a psychoeducational group intervention led by Primary Care (PC) nurses, aimed at patients of this kind. It is a randomized, multicenter clinical trial with intervention (IG) and control groups (CG), blind response variables, and a one year follow-up. The study included 380 patients ≥50 years of age from 18 PC teams. The participants presented depression (BDI-II > 12) and a physical comorbidity: diabetes mellitus type 2, ischemic heart disease, chronic obstructive pulmonary disease, and/or asthma. The IG (n = 204) received the psychoeducational intervention (12 weekly sessions of 90 min), and the CG (n = 176) had standard care. The patients were evaluated at baseline, and at 4 and 12 months. The main outcome measures were clinical remission of depressive symptoms (BDI-II ≤ 13) and therapeutic response (reduction of depressive symptoms by 50%). Remission was not significant at four months. At 12 months it was 53.9% in the IG and 41.5% in the CG. (OR = 0.61, 95% CI, 0.49–0.76). At 4 months the response in the IG (OR = 0.59, 95% CI, 0.44–0.78) was significant, but not at 12 months. The psychoeducational group intervention led by PC nurses for individuals with depression and physical comorbidity has been shown to be effective for remission at long-term and for therapeutic response at short-term.

Effect of an Educational Program on Healthcare Professionals' Readiness to Support Patients with Asthma, Allergies, and Chronic Obstructive Lung Disease for Improved Medication Adherence

PURPOSE

The aim of this study was to strengthen the healthcare professionals' readiness to support patients who have asthma, an allergy, and COPD for better medication adherence.

METHODS

The design was an educational intervention in a study population (n = 70) consisting of 66 nurses and four other allied healthcare professionals working in primary care with patients diagnosed with asthma, allergy, or COPD in a county in southern Sweden. As part of two training days, an educational intervention-consisting of lectures and workshops-was conducted. Both qualitative and quantitative data were collected. The qualitative data were collected during the workshops when the participants worked with fictitious patient cases. They documented in writing how they, based on the theoretical content in the educational intervention in combination with their clinical experiences, reasoned that the fictitious patients could be supported for better adherence. This documentation constituted qualitative data. The quantitative data were collected through questionnaires, which the participants completed before and after the intervention. Data from the questionnaires were statistically analyzed using descriptive statistics and paired t-tests. The qualitative data collected from the workshops were analyzed with content analysis.

RESULTS

The intervention increased the participants' knowledge of adherence (pre mean 3.95 versus post mean 4.18, p=0.001) and how to better support patients' adherence to medication (pre mean 3.71 versus post mean 3.98, p=0.001). Moreover, their knowledge of how to measure patients' adherence behavior (pre mean 3.02 versus post mean 3.54, p=0.001) and how to communicate with patients effectively about adherence was heightened (pre mean 3.92 versus post mean 4.13, p=0.011). Furthermore, participants felt that their readiness to support patients for better adherence had strengthened (pre mean 3.78 versus post mean 4.13, p=0.001). Individual adherence support for three fictitious patients with different adherence issues was developed.

CONCLUSION

An educational intervention focusing on adherence and communication equipped healthcare professionals with tools to support patients with asthma, an allergy, or COPD for better medication adherence.

Medication adherence among patients with chronic obstructive pulmonary disease treated in a primary general hospital during the COVID-19 pandemic

Background

The objective of this study was to investigate medication adherence and the associated influencing factors in patients with chronic obstructive pulmonary disease (COPD) who were treated in a primary general hospital in Shanghai China during the 2019 novel coronavirus (COVID-19) pandemic.

Methods

From March to April 2020, all of the COPD patients treated in our department in the last 7 years were interviewed by telephone. The basic patient data and each questionnaire item were collected, and influencing factors were analyzed by the Chi-square test, U test, and univariate and multivariate logistic regression analyses.

Results

A total of 191 patients with COPD were queried, and 84 (44.0%) valid questionnaires were obtained. Among them, individuals with group B symptoms were most represented (45.2%); 53.6% had Medical Research Council (MRC) dyspnea levels of 2 or above. Chronic obstructive pulmonary disease assessment test (CAT) had an average of 9 [3, 13], and 52.4% of patients used two-drug combination therapy. Medication adherence was both good in ordinary times and over the past 2 months of the pandemic, and 88.8% of patients had no acute exacerbation during the pandemic. The CAT scores of male patients <70 years old, and patients with general outpatient follow-up and regular gargling were reduced (P<0.05). Drug combination and doctor’s supervision were favorable factors affecting medication adherence during the 2 months of the pandemic, while possible depression was an unfavorable factor (P<0.05).

Conclusions

During the pandemic, medication adherence in patients with COPD was similar to that in regular times, and was significantly related to drug combination, doctor’s supervision, and accompanying mood disorders. An effective way to improve patient adherence and disease control could be strengthening follow-up education and diagnosing and treating depression and other complications.

Distribution, Temporal Stability and Appropriateness of Therapy of Patients With COPD in the UK in Relation to GOLD 2019

BACKGROUND

The 2019 Global Initiative for Chronic Obstructive Lung Disease (GOLD) report made recommendations for the assessment, initial and subsequent treatment chronic obstructive pulmonary disease (COPD) based on biomarkers, including blood eosinophil counts.

METHODS

We evaluated the distribution of UK COPD patients initiating maintenance therapy and established patients by GOLD group, the prevalence of comorbidities and appropriateness of therapy using electronic patient records from the Optimum Patient Care Research Database (OPCRD). Changes in effective GOLD group, therapy and exacerbation rates over the next 2 years were analysed.

FINDINGS

11,409 established COPD patients and 699 starting therapy were studied. 44·3%, 25·7%, 13·8% & 16·2% of established COPD patients and 45·2%, 28·5%, 15·7% & 10·6% initiating therapy were in GOLD groups A, B, C & D respectively.The overall proportion in each GOLD group was similar after 2 years but there was substantial movement of patients between groups. Diabetes and cardiovascular disease were the most common comorbidities in all groups in both cohorts.LAMA monotherapy was the commonest initial therapy in all GOLD groups. In both cohorts there was over-treatment with escalation, de-escalation or switching in nearly 50% during follow-up.In both cohorts, exacerbation rates were highest in group D and appeared higher in over-treated patients.

INTERPRETATION

Most patients are not at risk of exacerbations and co-morbidities are common. Many patients change effective GOLD group and therapy over time. Prescribing is not in accordance with guideline recommendations and many patients still appear over treated.

Development and Application of a Measurement Framework to Evaluate Safe, Effective and Efficient Medication Use Among Older Adults

Background

A majority of older adults in the United States (US) use prescription medications. Comprehensive population-level approaches to examine medication safety, effectiveness, and costs among older adults are needed.

Objectives

The objectives of this study were to develop a framework of quality measures spanning the domains of safety, effectiveness, and efficiency of prescription medication use among older adults, and to apply those measures using pharmacy claims data.

Methods

We performed a retrospective study among adults age 65 years and older of a US East Coast state who filled at least one prescription from a particular pharmacy chain during 2016 (N = 99,056). Firstly, we performed an environmental scan to identify quality measures and potentially relevant measures addressing prescription medication use. These measures were reviewed and rated by local geriatric pharmacotherapy experts. After evaluating feasibility, evidence, and relevance, a total of 19 measures representing the domains of safety (n = 7), effectiveness (n = 7), and efficiency (n = 5) were identified. These measures were then applied to an older adult population using prescription data for the year 2016 provided by a national pharmacy chain. All measures were configured such that a score of 100% corresponded to optimal performance.

Results

For the domain of safety, 12.8% of patients received a benzodiazepine chronically, 23.6% received central nervous system depressants, 16.7% received fluoroquinolones as first-line antibiotic therapy, and 21.9% of those who were prescribed opioids received them in excessive quantities. For the domain of effectiveness, one-fourth of the diabetes patients did not receive statins and angiotensin-acting medications, while 18.0% were not adherent to oral anticoagulant medications and 54% were not adherent to respiratory inhalers. For the domain of efficiency, 12.0% of the patients received prescriptions from five or more unique prescribers. Overall, 85.7%, 76.1%, and 87.9% of the older adults showed safe, effective, and efficient prescription medication use, respectively.

Conclusion

A novel approach to comprehensively examine the quality of medication use among older adults using prescription claims data is provided in our study. A considerable proportion of the older adults in our study received safe, effective, and efficient prescription medications. However, within each domain, several opportunities for improving the alignment of prescription medication use with current recommendations were identified.

Electronic supplementary material

The online version of this article (10.1007/s40801-019-00162-x) contains supplementary material, which is available to authorized users.

Dual versus triple therapy in patients hospitalized for COPD in France: a claims data study

Purposes

Following a hospitalization for COPD, dual and triple therapies were compared in terms of persistence and relations with outcomes (exacerbations, health care resource use and costs).

Methods

This was a historical observational database study. All patients aged ≥45 hospitalized for COPD between 2007 and 2015 were identified in a 1/97^th random sample of French claims data. Patients receiving dual therapy within 60 days after hospitalization were compared to patients receiving triple therapy, after propensity score matching on disease severity.

Results

Of the 3,089 patients hospitalized for COPD, 1,538 (49.8%) received either dual or triple therapy in the 2 months following inclusion, and 1,500 (48.6%) had at least 30 days of follow-up available; 846 (27.4%) received dual therapy, and 654 (21.2%) received triple therapy. After matching, the number of exacerbations was 2.4 per year in the dual vs 2.3 in the triple group (p=0.45). Among newly treated patients (n=206), persistence at 12 months was similar in the dual and triple groups (48% vs 41%, respectively, p=0.37). As compared to patients on dual therapy, more patients on triple therapy received oral corticosteroids (49.1 vs 40.4%, p=0.003) or were hospitalized for any reason (67% vs 55.8%, p=0.0001) or for COPD (35.3 vs 25.1%, p=0.0002) during follow-up. Cost of care was higher for patients on triple than for those on dual therapy (€11,877.1 vs €9,825.1, p=0.01).

Conclusion

Following hospitalizations for COPD, patients on dual and triple therapy experienced recurrent exacerbations, limited adherence to therapies and high cost of care. Patients on triple therapy appeared more severe than those on dual therapy, as reflected by exacerbations and health care resource use.

Medication management patterns among Medicare beneficiaries with chronic obstructive pulmonary disease who initiate nebulized arformoterol treatment

Purpose: Global evidence-based treatment strategies for chronic obstructive pulmonary disease (COPD) recommend using long-acting bronchodilators (LABDs) as maintenance therapy. However, COPD patients are often undertreated. We examined COPD treatment patterns among Medicare beneficiaries who initiated arformoterol tartrate, a nebulized long-acting beta2 agonist (LABA), and identified the predictors of initiation. Methods: Using a 100% sample of Medicare administrative data, we identified beneficiaries with a COPD diagnosis (ICD-9 490-492.xx, 494.xx, 496.xx) between 2010 and 2014 who had ≥1 year of continuous enrollment in Parts A, B, and D, and ≥2 COPD-related outpatient visits within 30 days or ≥1 hospitalization(s). After applying inclusion/exclusion criteria, three cohorts were identified: (1) study group beneficiaries who received nebulized arformoterol (n=11,886), (2) a subset of the study group with no LABD use 90 days prior to initiating arformoterol (n=5,542), and (3) control group beneficiaries with no nebulized LABA use (n=220,429). Logistic regression was used to evaluate predictors of arformoterol initiation. Odds ratios (ORs), 95% confidence intervals (CIs), and p values were computed. Results: Among arformoterol users, 47% (n=5,542) had received no LABDs 90 days prior to initiating arformoterol. These beneficiaries were being treated with a nebulized (50%) or inhaled (37%) short-acting bronchodilator or a systemic corticosteroid (46%), and many received antibiotics (37%). Compared to controls, beneficiaries who initiated arformoterol were significantly more likely to have had an exacerbation, a COPD-related hospitalization, and a pulmonologist or respiratory therapist visit prior to initiation (all p<0.05). Beneficiaries with moderate/severe psychiatric comorbidity or dual-eligible status were significantly less likely to initiate arformoterol, as compared to controls (all p<0.05). Conclusion: Medicare beneficiaries who initiated nebulized arformoterol therapy had more exacerbations and hospitalizations than controls 90 days prior to initiation. Findings revealed inadequate use of maintenance medications, suggesting a lack of compliance with evidence-based treatment guidelines.

Differences in Adherence Barriers to Inhaled Medicines between Japanese Patients with Chronic Obstructive Pulmonary Disease and Asthma Evaluated using the "Adherence Starts with Knowledge 20" (ASK-20) Questionnaire

Objective This multicenter, cross-sectional, non-interventional trial aimed to investigate adherence barriers to inhaled medicines when compared with oral medicines in Japanese patients with chronic obstructive pulmonary disease (COPD) and asthma. Methods The self-reporting "Adherence Starts with Knowledge 20" (ASK-20) questionnaire was administered for adherence barriers of inhaled and oral medicines to outpatients with regular clinic attendance. Results Patients with COPD and asthma reported different adherence barriers to inhaled medicines. Independent adherence barriers [odds ratio (95% confidence interval)] to inhaled medicines relative to those for oral medicines among patients with COPD and asthma were those related to item Q8 [ "I know if I am reaching my health goals"; 2.49 (1.39-4.47); p=0.0022] and item Q2 [ "I run out of my medicine because I do not get refills on time"; 2.69 (1.26-5.75); p=0.0127], respectively. Among patients with poor adherence to only inhaled medicines, those with COPD and asthma recognized item Q3 [ "consuming alcohol and taking medicines"; 6.63 (1.27-34.7); p<0.05] and item Q1 [ "forget to take medicines only sometimes"; 4.29 (1.83-10.0); p<0.05], respectively, were recognized as independent adherence barriers to inhaled medicines. The total ASK-20 scores and total barrier counts in patients with poor adherence to inhaled medicines were significantly higher than in those without poor adherence among patients with asthma (p=0.0057) but not those with COPD (p>0.05). Conclusion These results will aid in personalizing education on adherence to inhaled medicines among patients with COPD and asthma.

Psychological co-morbidities in COPD: Targeting systemic inflammation, a benefit for both?

COPD is a chronic lung disease characterized by persistent respiratory symptoms and airflow limitation due to airway and/or alveolar abnormalities. Furthermore, COPD is often characterized by extrapulmonary manifestations and comorbidities worsening COPD progression and quality of life. A neglected comorbidity in COPD management is mental health impairment defined by anxiety, depression and cognitive problems. This paper summarizes the evidence for impaired mental health in COPD and focuses on current pharmacological intervention strategies. In addition, possible mechanisms in impaired mental health in COPD are discussed with a central role for inflammation. Many comorbidities are associated with multi-organ-associated systemic inflammation in COPD. Considering the accumulative evidence for a major role of systemic inflammation in the development of neurological disorders, it can be hypothesized that COPD-associated systemic inflammation also affects the function of the brain and is an interesting therapeutic target for nutra- and pharmaceuticals.

Adherence to COPD treatment in Turkey and Saudi Arabia: results of the ADCARE study

Background

COPD affects millions of people worldwide. Poor treatment adherence contributes to increased symptom severity, morbidity and mortality. This study was designed to investigate adherence to COPD treatment in Turkey and Saudi Arabia.

Methods

An observational, cross-sectional study in adult COPD patients in Turkey and Saudi Arabia. Through physician-led interviews, data were collected on sociodemographics and disease history, including the impact of COPD on health status using the COPD Assessment Test (CAT); quality of life, using the EuroQol Five-Dimension questionnaire (EQ-5D); and anxiety and depression using the Hospital Anxiety and Depression Scale (HADS). Treatment adherence was measured using the 8-item Morisky Medication Adherence Scale (MMAS-8). Multivariate logistic regression analysis examined the predictors of non-adherence and the impact of adherence on symptom severity.

Results

Four hundred and five COPD patients participated: 199 in Turkey and 206 in Saudi Arabia. Overall, 49.2% reported low adherence (MMAS-8 <6). Of those, 74.7% reported high disease impact (CAT >15) compared to 58.4% reporting medium/high adherence (p=0.0008). Patients with low adherence reported a lower mean 3-level EQ-5D utility value (0.54±0.35) compared to those with medium/high adherence (0.64±0.30; p<0.0001). Depression with HADS score 8–10 or >10 was associated with lower adherence (OR 2.50 [95% CI: 1.43–4.39] and 2.43 [95% CI: 1.39–4.25], respectively; p=0.0008). Being a high school/college graduate was associated with better adherence compared with no high school (OR 0.57 [95% CI: 0.33–0.98] and 0.38 [95% CI: 0.15–1.00], respectively; p=0.0310). After adjusting for age, gender, and country, a significant association between treatment adherence (MMAS-8 score ≥6) and lower disease impact (CAT ≤15) was observed (OR 0.56 [95% CI: 0.33–0.95]; p=0.0314).

Conclusion

Adherence to COPD treatment is poor in Turkey and Saudi Arabia. Non-adherence to treatment is associated with higher disease impact and reduced quality of life. Depression, age, and level of education were independent determinants of adherence.

Pattern and Adherence to Maintenance Medication Use in Medicare Beneficiaries with Chronic Obstructive Pulmonary Disease: 2008-2013

Background: Maintenance medications provide symptomatic relief, improve lung function and reduce the risk of exacerbations in patients with chronic obstructive pulmonary disease (COPD). Despite their proven benefits, limited information exists on maintenance medication use and adherence among users. Objective: We examined the patterns and factors associated with the receipt of and adherence to maintenance medication in individuals with COPD. Methods: A retrospective cross-sectional study of 5% of Medicare beneficiaries enrolled in Parts A, B and D with COPD who received maintenance medication from 2008 to 2013 was conducted. Maintenance medication includes: inhaled corticosteroids (ICSs), long-acting beta2- agonists (LABAs) and long-acting muscarinic antagonists (LAMAs) alone or in combination. We examined the proportion of beneficiaries with COPD who had at least one prescription filled for maintenance medication. Among users of maintenance medications, we also examined adherence, defined as proportion of days covered (PDC) ≥80% over the year from the first maintenance medication prescription fill date. Results: Overall, maintenance medication (LAMAs, LABAs, ICSs and/or LABA/ICS) use increased from 67.8% in 2008 to 72.1% in 2013. The increase is related to increases in use of LABA/ICS, which rose from 41.1% in 2008 to 49.6% in 2013. Factors associated with receipt of maintenance medication include female gender, recent COPD hospitalization (odds ratio [OR] 1.63; 95% confidence interval [CI] 1.54-1.73), oxygen therapy (OR 1.74 95% CI, 1.68-1.81), dual eligibility status (OR 1.45; 95% CI 1.39-1.51), higher education level and evaluation by a pulmonary provider (OR 1.88; 95% CI 1.81-1.96). The overall adherence among maintenance medication users remained flat. The most important factor associated with adherence was dual eligibility status (OR, 1.67; 95% CI: 1.59-1.75). Conclusions: Receipt of maintenance medications increased during the study period and was higher in those with dual eligibility. Overall, adherence to maintenance medications was suboptimal and remained unchanged.

Depressive symptoms moderate the relationship between medication regimen complexity and objectively measured medication adherence in adults with heart failure

Patients with heart failure (HF) take many medications to manage their HF and comorbidities, and 20-50% experience depression. Depressed individuals with more complex medication regimens may be at greater risk for poor adherence. The aim of this study was to assess depressive symptoms as a moderator of the relationship between medication regimen complexity and medication adherence in an observational study of patients with HF. In hierarchical linear regression with the final sample of 299, the interaction of medication regimen complexity and depressive symptoms predicted medication adherence, p < .05. For individuals with higher levels of depressive symptoms [1 standard deviation (SD) above the mean], more regimen complexity was associated with lower adherence. For individuals with low (1 SD below the mean) or average levels of depressive symptoms, regimen complexity was unrelated to medication adherence. Care management strategies, including pillboxes and caregiver involvement, may be valuable in HF patients with depression.

Adherence and healthcare utilization among older adults with COPD and depression

BACKGROUND AND OBJECTIVE

Adherence to chronic obstructive pulmonary disease (COPD) maintenance medications and antidepressants may reduce healthcare utilization among multimorbid individuals with COPD and depression. We quantified the independent effects of adherence to antidepressants and COPD maintenance medications on healthcare utilization among individuals co-diagnosed with COPD and depression.

PROCEDURES

We conducted a retrospective cohort study using a 2006-2012 5% random sample of Medicare beneficiaries co-diagnosed with COPD and depression who had two or more prescription fills of both COPD maintenance medications and antidepressants. We measured adherence to medications using the proportion of days covered per 30-day period. The primary outcomes were all-cause emergency department (ED) visits and hospitalizations. Beneficiaries were followed over a minimum 12-month follow-up period.

RESULTS

Of the 16,075 beneficiaries meeting inclusion criteria, 21% achieved adherence ≥80% to COPD maintenance medications and 55% achieved adherence ≥80% to antidepressants. Compared to no use and controlling for antidepressant adherence and potential confounders, higher (≥80%) levels of adherence to COPD maintenance medications were associated with decreased risk of ED visits (hazard ratio (HR) 0.79; 95% CI 0.74, 0.83) and hospitalizations (HR 0.82; 95% CI 0.78, 0.87). Similarly, higher levels (≥80%) of adherence to antidepressants resulted in decreased risk of ED visits (HR 0.74; 95% CI 0.70, 0.78) and hospitalizations (HR 0.77; 95% CI 0.73, 0.81) compared to no use.

CONCLUSIONS

Clinicians can assist in the improved management of their multimorbid patients' health by treating depression among patients with COPD and monitoring and encouraging adherence to the regimens they prescribe.

Pre-Transplant Depression Is Associated with Length of Hospitalization, Discharge Disposition, and Survival after Liver Transplantation

Depression after liver transplantation has been associated with decreased survival, but the effects of pre-transplant depression on early and late post-transplant outcomes remain incompletely evaluated. We assessed all patients who had undergone single-organ liver transplantation at a single center over the prior 10 years. A diagnosis of pre-transplant depression, covariates, and the outcomes of interest were extracted from the electronic medical record. Potential covariates included demographics, etiology and severity of liver disease, comorbidities, donor age, graft type, immunosuppression, and ischemic times. In multivariable models adjusting for these factors, we evaluated the effect of pre-transplant depression on transplant length of stay (LOS), discharge disposition (home vs. facility) and long-term survival. Among 1115 transplant recipients with a median follow-up time of 5 years, the average age was 56±11 and MELD was 12±9. Nineteen percent of the study population had a history of pre-transplant depression. Pre-transplant depression was associated with longer LOS (median = 19 vs. 14 days, IRR = 1.25, CI = 1.13,1.39), discharge to a facility (36% vs. 25%, OR 1.70,CI = 1.18,2.45), and decreased survival (HR = 1.54,CI = 1.14,2.08) in this cohort, accounting for other potential confounders. In conclusion, pre-transplant depression was significantly associated with longer transplant length of stay, discharge to a facility, and mortality in this cohort.