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Case MA, Boorman EP, Ruvalcaba E, Vest MT, Hansel NN, Putcha N, Eakin MN. Guideline Alignment and Medication Concordance in COPD. CHEST PULMONARY 2024; 2:100017. [PMID: 38645884 PMCID: PMC11027369 DOI: 10.1016/j.chpulm.2023.100017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 04/23/2024]
Abstract
BACKGROUND Provider adherence to clinical treatment guidelines in COPD is low. However, for patients to receive guideline-aligned care, providers not only must prescribe guideline-aligned care, but also must communicate that regimen successfully to patients to ensure medication concordance. The rate of medication concordance between patients and providers and its impact on clinical management is unknown in COPD. RESEARCH QUESTION To examine rates of guideline alignment and medication concordance and to identify patient-level factors that place patients at risk for these types of poor disease management outcomes. STUDY DESIGN AND METHODS This study was a secondary data analysis of the Medication Adherence Research in COPD study (2017-2023). Participants were categorized into 2017 Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage. Medication regimens were classified as aligned or nonaligned with 2017 GOLD guidelines. Nonaligned regimens were stratified further into overuse and underuse categories. Medication concordance between provider-reported and participant-reported regimens was determined. Factors associated with guideline alignment and medication concordance were evaluated using logistic regression. RESULTS Of 191 participants, 51% of provider-reported regimens were guideline aligned, with 86% of nonaligned regimens reflecting overuse with an inhaled corticosteroid (ICS). Thirty-eight percent of participants reported different regimens than their providers, of which > 80% reflected participants not reporting medications their providers reported prescribing. Participants did not report long-acting muscarinic antagonists and long-acting beta-agonists at similar rates as ICSs. Greater symptom burden and absence of a pulmonologist on the care team were associated with both guideline misalignment and medication discordance. Cognitive impairment and Black race additionally were associated with medication discordance. INTERPRETATION Guideline misalignment and medication discordance were common and were driven by overuse of ICSs and unreported medications, respectively. The patient-level factors associated with medication discordance highlight the importance of improving patient-provider communication to improve clinical management in COPD.
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Affiliation(s)
- Meredith A Case
- Division of Pulmonary and Critical Care Medicine (M. A. C., e. P. B., E. R., N. N. H., N. P., and M. N. E.), Johns Hopkins University School of Medicine, Baltimore, MD; and the Division of Pulmonary and Critical Care Medicine (M. T. V.), Christiana Care Health System, Wilmington, DE
| | - Eric P Boorman
- Division of Pulmonary and Critical Care Medicine (M. A. C., e. P. B., E. R., N. N. H., N. P., and M. N. E.), Johns Hopkins University School of Medicine, Baltimore, MD; and the Division of Pulmonary and Critical Care Medicine (M. T. V.), Christiana Care Health System, Wilmington, DE
| | - Elizabeth Ruvalcaba
- Division of Pulmonary and Critical Care Medicine (M. A. C., e. P. B., E. R., N. N. H., N. P., and M. N. E.), Johns Hopkins University School of Medicine, Baltimore, MD; and the Division of Pulmonary and Critical Care Medicine (M. T. V.), Christiana Care Health System, Wilmington, DE
| | - Michael T Vest
- Division of Pulmonary and Critical Care Medicine (M. A. C., e. P. B., E. R., N. N. H., N. P., and M. N. E.), Johns Hopkins University School of Medicine, Baltimore, MD; and the Division of Pulmonary and Critical Care Medicine (M. T. V.), Christiana Care Health System, Wilmington, DE
| | - Nadia N Hansel
- Division of Pulmonary and Critical Care Medicine (M. A. C., e. P. B., E. R., N. N. H., N. P., and M. N. E.), Johns Hopkins University School of Medicine, Baltimore, MD; and the Division of Pulmonary and Critical Care Medicine (M. T. V.), Christiana Care Health System, Wilmington, DE
| | - Nirupama Putcha
- Division of Pulmonary and Critical Care Medicine (M. A. C., e. P. B., E. R., N. N. H., N. P., and M. N. E.), Johns Hopkins University School of Medicine, Baltimore, MD; and the Division of Pulmonary and Critical Care Medicine (M. T. V.), Christiana Care Health System, Wilmington, DE
| | - Michelle N Eakin
- Division of Pulmonary and Critical Care Medicine (M. A. C., e. P. B., E. R., N. N. H., N. P., and M. N. E.), Johns Hopkins University School of Medicine, Baltimore, MD; and the Division of Pulmonary and Critical Care Medicine (M. T. V.), Christiana Care Health System, Wilmington, DE
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Baldomero AK, Kunisaki KM, Wendt CH, Henning-Smith C, Hagedorn HJ, Bangerter A, Dudley RA. Guideline-discordant inhaler regimens after COPD hospitalization: associations with rurality, drive time to care, and fragmented care - a United States cohort study. LANCET REGIONAL HEALTH. AMERICAS 2023; 26:100597. [PMID: 37766800 PMCID: PMC10520452 DOI: 10.1016/j.lana.2023.100597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 08/30/2023] [Accepted: 09/05/2023] [Indexed: 09/29/2023]
Abstract
Background Many patients receive guideline-discordant inhaler regimens after chronic obstructive pulmonary disease (COPD) hospitalization. Geography and fragmented care across multiple providers likely influence prescription of guideline-discordant inhaler regimens, but these have not been comprehensively studied. We assessed patient-level differences in guideline-discordant inhaler regimens by rurality, drive time to pulmonary specialty care, and fragmented care. Methods Retrospective cohort analysis using national Veterans Health Administration (VA) data among patients who received primary care and prescriptions from the VA. Patients hospitalized for COPD exacerbation between 2017 and 2020 were assessed for guideline-discordant inhaler regimens in the subsequent 3 months. Guideline-discordant inhaler regimens were defined as short-acting inhaler/s only, inhaled corticosteroid (ICS) monotherapy, long-acting beta-agonist (LABA) monotherapy, ICS + LABA, long-acting muscarinic antagonist (LAMA) monotherapy, or LAMA + ICS. Rural residence and drive time to the closest pulmonary specialty care were obtained from geocoded addresses. Fragmented care was defined as hospitalization outside the VA. We used multivariable logistic regression models to assess associations between rurality, drive time, fragmentated care, and guideline-discordant inhaler regimens. Models were adjusted for age, sex, race/ethnicity, Charlson Comorbidity Index, Area Deprivation Index, and region. Findings Of 33,785 patients, 16,398 (48.6%) received guideline-discordant inhaler regimens 3 months after hospitalization. Rural residents had higher odds of guideline-discordant inhalers regimens compared to their urban counterparts (adjusted odds ratio [aOR] 1.18 [95% CI: 1.12-1.23]). The odds of receiving guideline-discordant inhaler regimens increased with longer drive time to pulmonary specialty care (aOR 1.38 [95% CI: 1.30-1.46] for drive time >90 min compared to <30 min). Fragmented care was also associated with higher odds of guideline-discordant inhaler regimens (aOR 1.56 [95% CI: 1.48-1.63]). Interpretation Rurality, long drive time to care, and fragmented care were associated with greater prescription of guideline-discordant inhaler regimens after COPD hospitalization. These findings highlight the need to understand challenges in delivering evidence-based care. Funding NIHNCATS grants KL2TR002492 and UL1TR002494.
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Affiliation(s)
- Arianne K. Baldomero
- Pulmonary, Allergy, Critical Care, and Sleep Medicine, Minneapolis VA Health Care System, Minneapolis, MN, USA
- Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Minnesota, Minneapolis, MN, USA
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, USA
| | - Ken M. Kunisaki
- Pulmonary, Allergy, Critical Care, and Sleep Medicine, Minneapolis VA Health Care System, Minneapolis, MN, USA
- Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Chris H. Wendt
- Pulmonary, Allergy, Critical Care, and Sleep Medicine, Minneapolis VA Health Care System, Minneapolis, MN, USA
- Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Carrie Henning-Smith
- Division of Health Policy and Management, University of Minnesota, Minneapolis, MN, USA
| | - Hildi J. Hagedorn
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, USA
| | - Ann Bangerter
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, USA
| | - R. Adams Dudley
- Pulmonary, Allergy, Critical Care, and Sleep Medicine, Minneapolis VA Health Care System, Minneapolis, MN, USA
- Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Minnesota, Minneapolis, MN, USA
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, USA
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Sethi S, Palli SR, Bengtson LGS, Buysman EK, Clark B, Sargent A, Shaikh A, Ferguson GT. Clinical and economic outcomes in patients with chronic obstructive pulmonary disease initiating maintenance therapy with tiotropium bromide/olodaterol or fluticasone furoate/umeclidinium/vilanterol. J Manag Care Spec Pharm 2023:1-16. [PMID: 37133429 PMCID: PMC10394184 DOI: 10.18553/jmcp.2023.22373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
BACKGROUND: Clinical practice guidelines recommend dual long-acting muscarinic antagonists (LAMAs)/long-acting β2agonists (LABAs) as maintenance therapy in patients with chronic obstructive pulmonary disease (COPD) and dyspnea or exercise intolerance. Escalation to triple therapy (TT) (LAMA/LABA/inhaled corticosteroid) is conditionally recommended for patients with continued exacerbations on dual LAMA/ LABA therapy. Despite this guidance, TT use is widespread across COPD severities, which could impact clinical and economic outcomes. OBJECTIVE: To compare COPD exacerbations, pneumonia events, and disease-related and all-cause health care resource utilization and costs (in 2020 US dollars) in patients initiating fixed-dose combinations of either LAMA/ LABA (tiotropium/olodaterol [TIO + OLO]) or TT (fluticasone furoate/umeclidinium/vilanterol [FF + UMEC + VI]). METHODS: This retrospective observational study of administrative claims included patients with COPD aged 40 years or older initiating TIO + OLO or FF + UMEC + VI from June 2015 to November 2019. TIO + OLO and FF + UMEC + VI cohorts in the overall and maintenance-naive populations were 1:1 propensity score matched on baseline demographics, comorbidities, COPD medications, health care resource utilization, and costs. Multivariable regression compared clinical and economic outcomes up to 12 months in FF + UMEC + VI vs TIO + OLO postmatched cohorts. RESULTS: After matching, there were 5,658 and 3,025 pairs in the overall and maintenance-naive populations, respectively. In the overall population, the risk of any (moderate or severe) exacerbation was 7% lower in FF + UMEC + VI vs TIO + OLO initiators (adjusted hazard ratio [aHR] = 0.93; 95% CI = 0.86-1.0; P = 0.047). There was no difference in the adjusted risk of any exacerbation in the maintenance-naive population (aHR = 0.99; 95% CI = 0.88-1.10). Pneumonia risk was not statistically different between cohorts in the overall (aHR = 1.12; 95% CI = 0.98-1.27) and maintenance-naive (aHR = 1.13; 95% CI = 0.95-1.36) populations. COPD- and/or pneumonia-related adjusted total annualized costs (95% CI) were significantly greater for FF + UMEC + VI vs TIO + OLO in the overall ($17,633 [16,661-18,604] vs $14,558 [13,709-15,407]; P < 0.001; differences [% of relative increase] = $3,075 [21.1%]) and maintenancenaive ($19,032 [17,466-20,598] vs $15,004 [13,786-16,223]; P < 0.001; $4,028 [26.8%]) populations, with significantly higher pharmacy costs with FF + UMEC + VI (overall: $6,567 [6,503-6,632] vs $4,729 [4,676-4,783]; P < 0.001; $1,838 [38.9%]; maintenance-naive: $6,642 [6,560-6,724] vs $4,750 [4,676-4,825]; P < 0.001; $1,892 [39.8%]). CONCLUSIONS: A lower risk of exacerbation was observed with FF + UMEC + VI vs TIO + OLO in the overall population but not among the maintenance-naive population. Patients with COPD initiating TIO + OLO had lower annualized costs than FF + UMEC + VI initiators in the overall and maintenance-naive populations. Thus, in the maintenance-naive population, initiation with dual LAMA/LABA therapy per practice guidelines can improve real-world economic outcomes. Study registration number: ClinicalTrials.gov (identifier: NCT05127304). DISCLOSURES: The study was funded by Boehringer Ingelheim Pharmaceuticals, Inc (BIPI). To ensure independent interpretation of clinical study results and enable authors to fulfill their role and obligations under the ICMJE criteria, BIPI grants all external authors access to relevant clinical study data. In adherence with the BIPI Policy on Transparency and Publication of Clinical Study Data, scientific and medical researchers can request access to clinical study data after publication of the primary manuscript in a peer-reviewed journal, regulatory activities are complete and other criteria are met. Dr Sethi has received honoraria/ fees for consulting/speaking from Astra-Zeneca, BIPI, and GlaxoSmithKline. He has received consulting fees for serving on data safety monitoring boards from Nuvaira and Pulmotect. He has received consulting fees from Apellis and Aerogen. His institution has received research funds for his participation in clinical trials from Regeneron and AstraZeneca. Ms Palli was an employee of BIPI at the time the study was conducted. Drs Clark and Shaikh are employees of BIPI. Ms Buysman and Mr Sargent are employees and Dr Bengtson was an employee of Optum, which was contracted by BIPI to conduct this study. Dr Ferguson reports grants and personal fees from Boehringer Ingelheim during the conduct of the study; grants from Novartis, Altavant, and Knopp; grants and personal fees from AstraZeneca, Verona, Theravance, Teva, and GlaxoSmithKline; and personal fees from Galderma, Orpheris, Dev.Pro, Syneos, and Ionis outside the submitted work. He was a paid consultant for BIPI for this study. The authors received no direct compensation related to the development of the manuscript. BIPI was given the opportunity to review the manuscript for medical and scientific accuracy as well as intellectual property considerations.
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Affiliation(s)
- Sanjay Sethi
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, NY
| | - Swetha R Palli
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT
| | - Lindsay G S Bengtson
- Optum Life Sciences, Eden Prairie, MN
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT
| | | | - Brendan Clark
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT
| | | | - Asif Shaikh
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT
| | - Gary T Ferguson
- Department of Medicine, Pulmonary Research Institute of Southeast Michigan, Farmington Hills
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Duan KI, Donovan LM, Spece LJ, Feemster LC, Bryant AD, Plumley R, Collins MP, Au DH. Trends and Rural-Urban Differences in the Initial Prescription of Low-Value Inhaled Corticosteroids among U.S. Veterans with Chronic Obstructive Pulmonary Disease. Ann Am Thorac Soc 2023; 20:668-676. [PMID: 36867427 PMCID: PMC10174122 DOI: 10.1513/annalsats.202205-458oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 02/27/2023] [Indexed: 03/03/2023] Open
Abstract
Rationale: Guidelines recommend inhaled corticosteroids (ICS) for patients with chronic obstructive pulmonary disease (COPD) and select indications, including asthma history, high exacerbation risk, or high serum eosinophils. ICS are commonly prescribed outside of these indications, despite evidence of harm. We defined a "low-value" ICS prescription as the receipt of an ICS without evidence of a guideline-recommended indication. ICS prescription patterns are not well characterized and could inform health system interventions to reduce low-value practices. Objectives: To evaluate the national trends in initial low-value ICS prescriptions in the U.S. Department of Veterans Affairs and to determine whether rural-urban differences in low-value ICS prescribing exist. Methods: We performed a cross-sectional study between January 4, 2010, and December 31, 2018, identifying veterans with COPD who were new users of inhaler therapy. We defined low-value ICS as prescriptions in patients with 1) no asthma, 2) low risk of future exacerbation (Global Initiative for Chronic Obstructive Lung Disease group A or B), and 3) serum eosinophils <300 cells/μl. We performed multivariable logistic regression to evaluate trends in low-value ICS prescription over time, adjusting for potential confounders. We performed fixed effects logistic regression to assess rural-urban prescribing patterns. Results: We identified a total of 131,009 veterans with COPD starting inhaler therapy, 57,472 (44%) of whom were prescribed low-value ICS as initial therapy. From 2010 to 2018, the probability of receiving low-value ICS as initial therapy increased by 0.42 percentage points per year (95% confidence interval, 0.31-0.53). Compared with urban residence, rural residence was associated with a 2.5-percentage-point (95% confidence interval, 1.9-3.1) higher probability of receiving low-value ICS as initial therapy. Conclusions: The prescription of low-value ICS as initial therapy is common and increasing slightly over time for both rural and urban veterans. Given the widespread and persistent nature of low-value ICS prescribing, health system leaders should consider system-wide approaches to address this low-value prescribing practice.
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Affiliation(s)
- Kevin I. Duan
- Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington; and
| | - Lucas M. Donovan
- Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington; and
| | - Laura J. Spece
- Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington; and
| | - Laura C. Feemster
- Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington; and
| | | | - Robert Plumley
- Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Margaret P. Collins
- Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - David H. Au
- Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington; and
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Myers LC, Murray RK, Donato BMK, Liu VX, Kipnis P, Shaikh A, Franchino-Elder J. Persistent Steroid Exposure Before Coronavirus Disease 2019 Diagnosis and Risk of Hospitalization in Patients With Chronic Obstructive Pulmonary Disease. CHRONIC OBSTRUCTIVE PULMONARY DISEASES (MIAMI, FLA.) 2023; 10:64-76. [PMID: 36472621 PMCID: PMC9995236 DOI: 10.15326/jcopdf.2022.0351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background It is unclear whether persistent inhaled steroid exposure in chronic obstructive pulmonary disease (COPD) patients before coronavirus disease 2019 (COVID-19) is associated with hospitalization risk. Objective Our objective was to examine the association between persistent steroid exposure and COVID-19-related hospitalization risk in COPD patients. Study Design and Methods This retrospective cohort study used electronic health records from the Kaiser Permanente Northern California health care system (February 2, 2020, to September 30, 2020) for patients aged ≥40 years with COPD and a positive polymerase chain reaction test result for COVID-19. Primary exposure was persistent oral and/or inhaled steroid exposure defined as ≥6 months of prescriptions filled in the year before the COVID-19 diagnosis. Multivariable logistic regression was performed for the primary outcome of COVID-19-related hospitalization or death/hospice referral. Steroid exposure in the month before a COVID-19 diagnosis was a covariate. Results Of >4.3 million adults, 697 had COVID-19 and COPD, of whom 270 (38.7%) had COVID-19-related hospitalizations. Overall, 538 (77.2%) were neither exposed to steroids in the month before COVID-19 diagnosis nor persistently exposed; 53 (7.6%) were exposed in the month before but not persistently; 23 (3.3%) were exposed persistently but not in the month before; and 83 (11.9%) were exposed both persistently and in the month before. Adjusting for all confounders including steroid use in the month before, the odds ratio for hospitalization was 0.77 (95% confidence interval 0.41-1.46) for patients persistently exposed to steroids before a COVID-19 diagnosis. Interpretation No association was observed between persistent steroid exposure and the risk of COVID-19-related hospitalization in COPD patients.
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Affiliation(s)
- Laura C Myers
- The Permanente Medical Group, Kaiser Permanente Northern California, Oakland, California, United States.,Division of Research, Kaiser Permanente Northern California, Oakland, California, United States
| | | | - Bonnie M K Donato
- Health Economics and Outcomes Research, Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, Connecticut, United States
| | - Vincent X Liu
- The Permanente Medical Group, Kaiser Permanente Northern California, Oakland, California, United States.,Division of Research, Kaiser Permanente Northern California, Oakland, California, United States
| | - Patricia Kipnis
- The Permanente Medical Group, Kaiser Permanente Northern California, Oakland, California, United States.,Division of Research, Kaiser Permanente Northern California, Oakland, California, United States
| | - Asif Shaikh
- Clinical Development and Medical Affairs, Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, Connecticut, United States
| | - Jessica Franchino-Elder
- Health Economics and Outcomes Research, Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, Connecticut, United States
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6
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Bhatt SP, Blauer-Peterson C, Buysman EK, Bengtson LGS, Paine Iii SR. Trends and Characteristics of Global Initiative for Chronic Obstructive Lung Disease Guidelines-Discordant Prescribing of Triple Therapy Among Patients with COPD. CHRONIC OBSTRUCTIVE PULMONARY DISEASES (MIAMI, FLA.) 2022; 9:135-153. [PMID: 35157792 PMCID: PMC9166325 DOI: 10.15326/jcopdf.2021.0256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Triple therapy (long-acting muscarinic antagonist [LAMA] plus long-acting beta2-agonist [LABA] plus inhaled corticosteroid [ICS]) is recommended by the Global initiative for chronic Obstructive Lung Disease (GOLD) for moderate-to-severe chronic obstructive pulmonary disease (COPD) with a history of frequent and/or severe exacerbation(s) and dyspnea while using dual bronchodilators. However, many patients receive triple therapy contrary to these recommendations. This study describes factors associated with GOLD-discordant triple therapy initiation. METHODS This retrospective analysis included patients aged 40 and above, with ≥1 COPD diagnosis, who initiated triple therapy (initiation=index date) during the period January 1, 2014 to December 31, 2018 and had ≥12 months pre-index continuous enrollment (baseline). Triple therapy comprised ≥30 days of overlapping LAMA, LABA, and ICS treatments (open triple therapy), or single-inhaler fluticasone furoate/umeclidinium/vilanterol (closed triple therapy). Cohorts were defined based on the absence of baseline maintenance medication use ("maintenance-naïve"), and/or exacerbations ("exacerbation-discordant"), or "dual-discordant" (discordant on both measures). All triple therapy initiators, overall and for each cohort, were described, and predictors of GOLD-discordant triple therapy initiation were identified. RESULTS Among 21,711 triple therapy initiators, 34.4% were maintenance-naïve, 61.9% exacerbation-discordant, and 22.2% dual-discordant. Triple therapy initiation appeared to increase during the period 2016 to 2018. In 2018 alone, 31.9% and 58.3% of open triple therapy patients were maintenance-naïve and exacerbation-discordant, respectively, versus 37.6% and 64.4% of closed triple therapy patients. Closed triple therapy initiators had 1.65 times greater risk of dual discordance than open triple therapy initiators. Exacerbation-discordant patients initiating closed triple therapy were 1.61 times more likely to be maintenance-naïve than those initiating open triple therapy. CONCLUSION A substantial proportion of COPD patients initiating triple therapy do not meet GOLD recommendations regarding exacerbation history and/or prior maintenance therapy. Compared with open triple therapy, closed triple therapy initiators were more likely to be dual discordant.
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Affiliation(s)
- Surya P Bhatt
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Cori Blauer-Peterson
- Health Economics and Outcomes Research, Optum, Eden Prairie, Minnesota, United States
| | - Erin K Buysman
- Health Economics and Outcomes Research, Optum, Eden Prairie, Minnesota, United States
| | - Lindsay G S Bengtson
- Health Economics and Outcomes Research, Optum, Eden Prairie, Minnesota, United States
| | - Swetha R Paine Iii
- Value Demonstration Team, Boehringer Ingelheim, Ridgefield, Connecticut, United States
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7
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Suissa S, Dell'Aniello S, Ernst P. Discontinuation of Inhaled Corticosteroids from Triple Therapy in COPD: Effects on Major Outcomes in Real World Clinical Practice. COPD 2022; 19:133-141. [PMID: 35392746 DOI: 10.1080/15412555.2022.2045265] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Recent reports provide evidence-based guidelines for the withdrawal of inhaled corticosteroids (ICS) in COPD, but data on patients treated with ICS-based triple therapy are sparse and contradictory. We assessed the effect of ICS discontinuation on the incidence of severe exacerbation and pneumonia in a real-world population of patients with COPD who initiated triple therapy. We identified a cohort of patients with COPD treated with LAMA-LABA-ICS triple therapy during 2002-2018, age 50 or older, from the UK's CPRD database. Subjects who discontinued ICS were matched 1:1 on time-conditional propensity scores to those continuing ICS and followed for one year. Hazard ratios (HR) of severe exacerbation and pneumonia were estimated using Cox regression. The cohort included 42,667 patients who discontinued ICS matched to 42,667 who continued ICS treatment. The hazard ratio of a severe exacerbation with ICS discontinuation relative to ICS continuation was 0.86 (95% CI: 0.78-0.95), while for severe pneumonia it was 0.96 (95% CI: 0.88-1.05). The incidence of severe exacerbation after ICS discontinuation was numerically higher than after continuation among patients with two or more exacerbations in the prior year (HR 1.09; 95% CI: 0.94-1.26) and among those with FEV1 <30% predicted (HR 1.29; 95% CI: 1.04-1.59). This large real-world study in the clinical setting of COPD treatment suggests that certain patients on triple therapy can be safely withdrawn from ICS and remain on bronchodilator therapy. As residual confounding cannot be ruled out, ICS discontinuation is not warranted for patients with multiple exacerbations and with very severe airway obstruction.
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Affiliation(s)
- Samy Suissa
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Québec, Canada.,Departments of Epidemiology and Biostatistics, and of Medicine, McGill University, Montreal, Québec, Canada
| | - Sophie Dell'Aniello
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Québec, Canada
| | - Pierre Ernst
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Québec, Canada.,Departments of Epidemiology and Biostatistics, and of Medicine, McGill University, Montreal, Québec, Canada
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8
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Dhar R, Talwar D, Salvi S, Muralimohan BV, Panchal S, Patil S, Bhagat S, Khatri N, Barkate H. Use of single-inhaler triple therapy in the management of obstructive airway disease: Indian medical experts' review. ERJ Open Res 2022; 8:00556-2021. [PMID: 35350278 PMCID: PMC8958219 DOI: 10.1183/23120541.00556-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 01/07/2022] [Indexed: 11/05/2022] Open
Abstract
Obstructive airway disease (OAD), which includes COPD and asthma, is the leading cause of morbidity and mortality in India. Long-acting bronchodilators (long-acting β2 agonists (LABAs) and/or long-acting muscarinic antagonists (LAMAs)) and inhaled corticosteroids (ICS) have a vital role in the management of patients with OAD. While symptom burden and exacerbations are common amongst treated patients, poor adherence to inhaler therapy is a frequent challenge. Better treatment options that optimise symptom control, improve quality of life, reduce exacerbation risk and improve adherence are desired. Triple therapy (ICS/LABA/LAMA) is recommended in the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2021 guidelines for symptomatic COPD patients on ICS/LABA or LABA/LAMA, and who are at increased risk for frequent or severe exacerbations. Similarly, add-on LAMA is recommended in uncontrolled asthma patients on medium- to high-dose ICS/LABA by the Global Initiative for Asthma (GINA) 2021 guideline. In the real world, high-risk and overlapping phenotypes exist, which necessitate early initiation of triple therapy. We aim to provide an expert review on the use of single-inhaler triple therapy (SITT) for OAD management in global and Indian settings, knowledge from which can be extrapolated for appropriate treatment of Indian patients. The OAD population in India may benefit from early optimisation to SITT characterised by a high burden of exacerbating OAD, nonsmoker COPD and asthma-COPD overlap.
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Affiliation(s)
- Raja Dhar
- Dept of Pulmonology, The Calcutta Medical Research Institute, Kolkata, India
| | - Deepak Talwar
- Metro Respiratory Center, Pulmonology and Sleep Medicine, Metro Hospitals and Heart Institute, Noida, India
| | - Sundeep Salvi
- Pulmocare Research and Education (PURE) Foundation, Pune, India
| | - B V Muralimohan
- Dept of Internal Medicine and Pulmonology, Narayana Hrudayalaya - Mazumdar Shaw Medical Center, Bengaluru, India
| | - Sagar Panchal
- Global Medical Affairs, Glenmark Pharmaceuticals Ltd, Mumbai, India
| | - Saiprasad Patil
- Global Medical Affairs, Glenmark Pharmaceuticals Ltd, Mumbai, India
| | - Sagar Bhagat
- Global Medical Affairs, Glenmark Pharmaceuticals Ltd, Mumbai, India
| | - Nishtha Khatri
- Global Medical Affairs, Glenmark Pharmaceuticals Ltd, Mumbai, India
| | - Hanmant Barkate
- Global Medical Affairs, Glenmark Pharmaceuticals Ltd, Mumbai, India
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9
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Effect of Respiration Training-Assisted Western Medicine Therapy on Activity Tolerance, Pulmonary Function, and Quality of Life of Chronic Obstructive Pulmonary Disease Patients in the Stable Phase. JOURNAL OF HEALTHCARE ENGINEERING 2022; 2022:9427602. [PMID: 35399844 PMCID: PMC8986397 DOI: 10.1155/2022/9427602] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 03/01/2022] [Accepted: 03/16/2022] [Indexed: 02/07/2023]
Abstract
Objective To explore the effect of respiration training-assisted western medicine therapy on activity tolerance, pulmonary function, and quality of life (QOL) of chronic obstructive pulmonary disease (COPD) patients in the stable phase. Methods The medical data of 90 COPD patients in the stable phase treated in the respiratory medicine of our hospital (November 2020-November 2021) were chosen for the retrospective analysis, and the patients were split into group A (n = 45, respiration training-assisted western medicine therapy) and group B (n = 45, western medicine therapy) according to the clinical reception order, so as to record and compare the activity tolerance, lung function, and QOL between the groups after intervention. Results Compared with group B after intervention, group A showed greatly longer mean 6-min walking distance, significantly lower St. George's Respiratory Questionnaire (SGRQ) score, significantly higher specific airway conductance (sGAW) and level values of various lung function indicators, and significantly lower level values of airway resistance (RAW) and specific airway resistance (sRAW) (p all<0.001); the total effective rate was significantly higher in group A (p < 0.05). Conclusion Respiration training-assisted western medicine therapy is a dependable way to improve the activity tolerance of COPD patients in the stable phase, and such strategy largely improves patients' lung function and QOL. Deeper studies will be helpful to establish a preferable solution for such patients.
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10
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Keller TL, Wright J, Donovan LM, Spece LJ, Duan K, Sulayman N, Dominitz A, Curtis JR, Au DH, Feemster LC. Association of Patient and Primary Care Provider Factors with Outpatient COPD Care Quality. CHRONIC OBSTRUCTIVE PULMONARY DISEASES (MIAMI, FLA.) 2022; 9:55-67. [PMID: 34915603 PMCID: PMC8893974 DOI: 10.15326/jcopdf.2021.0232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/29/2021] [Indexed: 06/14/2023]
Abstract
RATIONALE Large gaps exist between guideline-recommended outpatient chronic obstructive pulmonary disease (COPD) care and clinical practice. Seeking to design effective interventions, we identified patient and primary care provider (PCP) characteristics associated with receiving evidence-based COPD care. METHODS We performed an observational study of adults aged ≥ 40 years with clinically diagnosed COPD who received care at 2 University of Washington-affiliated primary care clinics between June 1, 2011, and June 1, 2013. Our primary outcome was the proportion of evidence-based outpatient COPD quality measures received through primary or pulmonary care. Among all patients, we assessed spirometry completion, respiratory symptom identification, smoking status ascertainment, oxygen saturation measurement, and guideline-concordant inhaled therapy prescription. We also determined confirmation of airflow obstruction, oxygen prescription, smoking cessation intervention, and pulmonary rehabilitation referral if eligible. We used multivariable mixed effects linear regression to estimate the association of patient and PCP characteristics with the primary outcome. RESULTS Among 641 patients, 382 were male (59.6%) with mean age 63.6 (standard deviation [SD] 10.6) years. Most patients currently smoked (N=386, 60.2%). Patients saw 150 unique PCPs during 5.3 (SD 3.2) PCP visits, with 107 completing pulmonary referrals (16.7%). Patients received 67.5% (SD 18.4%) of eligible (median 7 [interquartile range 6-7]) evidence-based quality measures. After adjustment, pulmonary referral was associated with a higher receipt of outpatient quality measures (ß117.7%, 95% confidence interval: 12.6%, 22.7%). Patient demographics, comorbidities, and PCP identity/characteristics were not associated with outpatient care quality. CONCLUSIONS The quality of outpatient COPD care was suboptimal. Future studies should investigate if engaging pulmonologists in COPD management improves care quality.
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Affiliation(s)
- Thomas L Keller
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington, United States
| | - Jennifer Wright
- Department of Medicine, University of Washington, Seattle, Washington, United States
| | - Lucas M Donovan
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington, United States
- Health Services Research and Development Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, Seattle, Washington, United States
| | - Laura J Spece
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington, United States
- Health Services Research and Development Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, Seattle, Washington, United States
| | - Kevin Duan
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington, United States
| | - Nadiyah Sulayman
- Health Services Research and Development Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, Seattle, Washington, United States
| | - Alexandria Dominitz
- Health Services Research and Development Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, Seattle, Washington, United States
| | - J Randall Curtis
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington, United States
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, United States
| | - David H Au
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington, United States
- Health Services Research and Development Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, Seattle, Washington, United States
| | - Laura C Feemster
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington, United States
- Health Services Research and Development Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, Seattle, Washington, United States
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11
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Poon M, Pequeno P, Aaron SD, Stanbrook M, Wong H, Cram P, Gershon AS. Trends in non-receipt of recommended chronic obstructive pulmonary disease medication. ERJ Open Res 2022; 8:00584-2021. [PMID: 35479295 PMCID: PMC9035603 DOI: 10.1183/23120541.00584-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 11/24/2021] [Indexed: 11/05/2022] Open
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12
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Brennan V, Mulvey C, Costello RW. The clinical impact of adherence to therapy in airways disease. Breathe (Sheff) 2021; 17:210039. [PMID: 34295431 PMCID: PMC8291957 DOI: 10.1183/20734735.0039-2021] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 05/12/2021] [Indexed: 11/13/2022] Open
Abstract
For a physician, the final step of a consultation consists of developing a treatment plan and prescription. For the patient, this is the start of a process. First, their role in the treatment plan must be clarified, then they may have to obtain an alternative prescription from their general practitioner. Next, they must have the prescription filled and dispensed from the pharmacy and, finally, they must take the treatment on time and for the required duration. For people with chronic conditions, this requires repeatedly returning to the pharmacy for the prescription to be renewed and dispensed. Given that many patients are on multiple treatment regimens and may have poor health literacy, this becomes a complex process and it is not surprising that this can, and frequently does, go wrong. Research shows that when a patient does not adhere to standard asthma or COPD treatment, they report poor control and overuse of rescue β-agonists, experience frequent exacerbations and are often prescribed add-on treatments such as biological agents. In short, poor treatment adherence can manifest in the same way as a refractory condition. These clinical features should prompt a clinician to investigate poor adherence as they might investigate a new blood or radiological finding. Examining a patient's prescription refill records or a digitally enabled inhaler can demonstrate a number of patterns of inhaler use. A small minority regularly use their treatment as prescribed but many appear to be “cluster users”: a group of patients who use their treatment correctly when they are unwell, but once some level of personal control is attained, they cease or reduce their use. Others may cease using their treatment because they are not perceiving a benefit or because an alternative condition accounts for their symptoms. In other words, clinicians can consider that treatment adherence is like a clinical sign: something to be investigated so that they may understand the patient's condition better. Suspected poor treatment adherence should be treated as a clinical sign. It should be suspected among patients with asthma and COPD who have excessive reliever use or recurrent exacerbations. It can be detected using pharmacy data or electronic devices.https://bit.ly/3oqwS5L
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Affiliation(s)
- Vincent Brennan
- Beaumont Hospital, Dublin, Ireland.,INCA Group, Dept of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Christopher Mulvey
- INCA Group, Dept of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Richard W Costello
- Beaumont Hospital, Dublin, Ireland.,INCA Group, Dept of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
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13
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Gershon AS, Pequeno P, Machado AA, Aaron SD, Kendzerska T, Luo J, Stanbrook MB, Tan WC, Porter J, To T. FACTORS ASSOCIATED WITH NON-RECEIPT OF RECOMMENDED CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) MEDICATIONS: A POPULATION STUDY. Chest 2021; 160:1670-1680. [PMID: 34144022 DOI: 10.1016/j.chest.2021.05.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 05/04/2021] [Accepted: 05/25/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) medications reduce exacerbations and improve quality of life. Despite this, some individuals do not receive medications recommended by practise guidelines. RESEARCH QUESTION How common is non-receipt of recommended medications among people with COPD and what are factors associated with non-receipt? STUDY DESIGN AND METHODS We conducted a population cohort study in Ontario, Canada, a province with universal health care insurance and medication coverage for those aged 65 and older. Health administrative data were used to identify people 66 years of age or older with physician-diagnosed COPD as of 2018 and group them into lower or higher risk for future COPD exacerbation groups. Proportions of patients in each group who did not receive medications recommended by COPD guidelines were determined. Generalized estimating equation modelling was used to determine associations between patient and physician factors and non-receipt of recommended medications. RESULTS About 54% and 88% of people with COPD receoved sufficient recommended medications in the low and high risk of exacerbation groups, respectively. Longer duration of COPD, higher comorbidity, dementia, and older physician age were associated with non-receipt of recommended medications in both groups. People who had a co-diagnosis of asthma and who received care by a pulmonologist and spirometry were more likely to receive recommended medication . INTERPRETATION COPD medications appear underused by the COPD population and various factors are associated with sub-optimal receipt. Targeting these factors would help improve the care and health of people with COPD.
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Affiliation(s)
- Andrea S Gershon
- Department of Medicine and Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; ICES, Toronto and Ottawa, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; The Hospital for Sick Children Research Institute, Toronto, ON, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada.
| | | | | | - Shawn D Aaron
- The Ottawa Hospital Research Institute, 1053 Carling Ave, Ottawa, ON, Canada
| | - Tetyana Kendzerska
- ICES, Toronto and Ottawa, ON, Canada; The Ottawa Hospital Research Institute, 1053 Carling Ave, Ottawa, ON, Canada
| | - Jin Luo
- ICES, Toronto and Ottawa, ON, Canada
| | - Matthew B Stanbrook
- ICES, Toronto and Ottawa, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada; University Health Network, Toronto, ON, Canada
| | - Wan C Tan
- University of British Columbia, UBC James Hogg Research Laboratories, Providence Heart and Lung Institute, Vancouver, BC, Canada
| | | | - Teresa To
- ICES, Toronto and Ottawa, ON, Canada; The Hospital for Sick Children Research Institute, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
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14
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Duan KI, Spece LJ, Wong ES, Feemster LC, Donovan LM, Griffith MF, Keller TL, Bryant AD, Au DH. Low-Value Inhaled Corticosteroids in Chronic Obstructive Pulmonary Disease and the Association with Healthcare Utilization and Costs. Ann Am Thorac Soc 2021; 18:989-996. [PMID: 33290180 PMCID: PMC8456735 DOI: 10.1513/annalsats.202009-1128oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 12/08/2020] [Indexed: 11/20/2022] Open
Abstract
Rationale: Inhaled corticosteroids (ICS) are not first-line therapy for patients with chronic obstructive pulmonary disease (COPD) at low risk of exacerbations, but they are commonly prescribed despite evidence of harm. We consider ICS prescription in this population to be of "low value." The association of low-value ICS with subsequent healthcare utilization and costs is unknown. Understanding this relationship could inform efforts to reduce the delivery of low-value care. Objectives: To determine whether low-value ICS prescribing is associated with higher outpatient healthcare utilization and costs among patients with COPD who are at low risk of exacerbation. Methods: We performed a cohort study between January 1, 2010, and December 31, 2018, identifying a cohort of veterans with COPD who performed pulmonary function tests (PFTs) at 21 Veterans Affairs medical centers nationwide. Patients were defined as having low exacerbation risk if they experienced less than two outpatient exacerbations and no hospital admissions for COPD in the year before PFTs. Our primary exposure was the receipt of an ICS prescription in the 3 months before the date of PFTs. Our primary outcomes were outpatient utilization and outpatient costs in the 1 year after PFTs. For inference, we generated negative binomial models for utilization and generalized linear models for costs, adjusting for confounders. Results: We identified a total of 31,551 patients with COPD who were at low risk of exacerbation. Of these patients, 9,742 were prescribed low-value ICS (mean [standard deviation (SD)] age, 69 [9] yr), and 21,809 were not prescribed low-value ICS (mean [SD] age, 68 [9] yr). Compared with unexposed patients, those exposed to low-value ICS had 0.53 more encounters per patient per year (95% confidence interval CI, 0.23-0.83) and incurred $154.72 higher costs/patient/year (95% CI, $45.58-$263.86). Conclusions: Low-value ICS prescription was associated with higher subsequent outpatient healthcare utilization and costs. Potential mechanisms for the observed association are that 1) low-value ICS may be a marker of poor respiratory symptom control, 2) there is confounding by indication, or 3) low-value ICS results in increased drug costs or utilization. Health systems should identify low-value ICS prescriptions as a target to improve value-based care.
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Affiliation(s)
- Kevin I. Duan
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
| | - Laura J. Spece
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
| | - Edwin S. Wong
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Department of Health Services, University of Washington, Seattle, Washington
| | - Laura C. Feemster
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
| | - Lucas M. Donovan
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
| | - Matthew F. Griffith
- Health Services Research and Development, Veterans Affairs Eastern Colorado Health Care System, Aurora, Colorado; and
- Division of Pulmonary Sciences and Critical Care, University of Colorado, Aurora, Colorado
| | - Thomas L. Keller
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
| | - Alexander D. Bryant
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
| | - David H. Au
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
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15
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Martinez FJ, Thomashow B, Sapir T, Simone L, Carter J, Han M. Does Evaluation and Management of COPD Follow Therapeutic Strategy Recommendations? CHRONIC OBSTRUCTIVE PULMONARY DISEASES (MIAMI, FLA.) 2021; 8:230-242. [PMID: 33610138 DOI: 10.15326/jcopdf.2020.0175] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction Recommendations for chronic obstructive pulmonary disease (COPD) diagnosis and management requires symptom and exacerbation risk assessment. Adherence to these recommendations appears to be limited. We examined the impact of a COPD quality improvement (QI) program in the Southeastern United States. Methods From 2017 to 2018, nine pulmonary and 15 primary care physicians were included in our study and asked to identify 6 to 7 of their COPD patients using maintenance COPD medications with at least 2 office visits in the past year. A separate group of COPD patients (n=135 pulmonary and 165 primary care) from the same practices were evaluated. Physicians underwent focused, educational, peer-to-peer small group webinars. Data were collected from physicians and their patients using a systematic survey. Chart audits occurred at baseline and 6 months after the webinars. Results The majority of physicians (67%) saw ≥ 20 COPD patients/week. There were important discrepancies between the care clinicians thought they provided, and the care recalled by their patients. Clinicians felt that 33% of their patients experienced at least 2 exacerbations in the past year; 56% of their patients reported this frequency. There was discrepancy in the clinicians' interpretations and the patients' reasons for discontinuing their medications and in the use of referrals. Self-reported changes were noted by clinicians after educational webinars and improvements in patient care were noted in the year following intervention. Conclusion We identified notable discrepancies between the clinicians' impression of care provided and the components actually recalled by their patients. We also identified improvements in processes of care and outcomes following an educational intervention based on the principles of audit and feedback.
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Affiliation(s)
- Fernando J Martinez
- Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, United States
| | - Byron Thomashow
- Columbia University, New York Presbyterian Hospital, New York, New York, United States
| | - Tamar Sapir
- PRIME Education, LLC, Fort Lauderdale, Florida, United States
| | - Laura Simone
- PRIME Education, LLC, Fort Lauderdale, Florida, United States
| | - Jeffrey Carter
- PRIME Education, LLC, Fort Lauderdale, Florida, United States
| | - MeiLan Han
- University of Michigan Health System, Ann Arbor, Michigan, United States
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16
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Palli SR, Zhou S, Shaikh A, Willey VJ. Effect of compliance with GOLD treatment recommendations on COPD health care resource utilization, cost, and exacerbations among patients with COPD on maintenance therapy. J Manag Care Spec Pharm 2021; 27:625-637. [PMID: 33779246 PMCID: PMC10394222 DOI: 10.18553/jmcp.2021.20390] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND: The Global Initiative for Chronic Obstructive Lung Disease (GOLD) report for the management of chronic obstructive pulmonary disease (COPD) focuses on reducing existing symptoms, decreasing the risk of future exacerbations, and improving health status by recommending specific drug therapy based on exacerbation risk and symptoms. However, disparities exist between evidence-based recommendations and clinical practice. Research that quantifies the real-world effect of COPD regimen alignment with the GOLD recommendations on clinical and economic outcomes is needed. OBJECTIVE: To compare COPD-related health care resource utilization (HRU) and costs, as well as exacerbation rates, among patients with COPD on maintenance therapy based on 2017 GOLD treatment recommendation compliance status per GOLD ABCD risk group classification in a U.S. commercially insured/Medicare Advantage population. METHODS: This retrospective cohort study utilized administrative claims data in the HealthCore Integrated Research Database. The COPD population was identified using a previously validated claims-based predictive model. Among this population, patients with ≥ 1 claim for a COPD maintenance medication (earliest maintenance fill-date = index date) between January 1, 2014, and March 31, 2017, were identified. Patients were required to be aged ≥ 40 years, have ≥ 12 months of pre-index and ≥ 30 days of post-index health plan enrollment, with no diagnosis for asthma, cystic fibrosis, and/or lung cancer at any time from January 1, 2013, to March 31, 2018. Patients were categorized into exacerbation risk/symptomatology groups according to the 2017 GOLD ABCD assessment recommendations and were then classified into treatment-compliance status based on their maintenance therapy. Multivariable analyses were conducted to examine post-index COPD-related HRU, costs, and exacerbations by compliance status. RESULTS: The primary analytical study sample included 38,382 patients in the GOLD A/B group and 6,525 in the GOLD C/D group. Patients were further categorized into GOLD A (n = 19,345), B (n = 19,037), C (n = 1,865), and D (n = 4,670). GOLD-compliant regimens were observed in 32.9% of patients in the GOLD A/B group and in 58.9% of patients in the GOLD C/D group. Inhaled corticosteroid-containing regimens were the most commonly observed noncompliant regimen. Patients on compliant regimens had significantly fewer COPD-related inpatient and emergency department visits and therefore had significantly lower COPD-related medical costs in both the GOLD A/B and C/D cohorts. Similar results were observed for individual GOLD cohorts B, C, and D. These savings were offset by increased pharmacy expenditures. Being on GOLD guideline-compliant regimens significantly reduced the risk of exacerbation by 8% (hazard ratio [HR] = 0.92; P < 0.0001) in the GOLD A/B cohort and by 12% (HR = 0.88; P = 0.0005) in the GOLD C/D cohort, and was also associated with a significantly reduced exacerbation rate in the GOLD A/B (rate ratio [RR] = 0.93; P < 0.0001) and GOLD C/D (RR = 0.93; P = 0.0129) groups. CONCLUSIONS: This study suggests a continuing trend of high prevalence of suboptimal prescriber compliance to GOLD treatment recommendations. Treatment regimens compliant with GOLD recommendations were associated with improvement in exacerbations, reduced COPD-related HRU, and COPD-related medical cost offsets. DISCLOSURES: This study was funded by Boehringer Ingelheim Pharmaceuticals, Inc. (BIPI). BIPI was given the opportunity to review the manuscript for medical and scientific accuracy as well as intellectual property considerations. Palli and Shaikh are employees of BIPI. Willey is an employee of HealthCore, which was contracted by BIPI to conduct this study. Zhou was an employee of HealthCore at the time of study execution. Data were presented in part during an AMCP webinar (recording not made public) held in lieu of the Spring 2020 AMCP conference, which was canceled due to the COVID-19 pandemic.
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Affiliation(s)
| | | | - Asif Shaikh
- Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT
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17
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Ehteshami-Afshar S, Crothers K, Rodwin B, Bade B, Brandt C, Akgün KM. Does pulmonary subspecialty referral from primary care affect the adherence to vaccination recommendations in COPD patients? Respir Res 2021; 22:50. [PMID: 33579277 PMCID: PMC7880521 DOI: 10.1186/s12931-021-01639-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 01/27/2021] [Indexed: 01/30/2023] Open
Abstract
The importance of vaccinations for COPD patients has been previously described. However, there is still a gap between guideline recommendations and the implementation of preventive care delivery for these patients. Specially, the rise of SARS-CoV-2 pandemic has made the significance of vaccination adherence more critical to address. Our study showed that referral to pulmonary clinic is associated with increased odds of receiving influenza (OR = 1.97, [95% CI 1.07, 3.65]) and pneumococcal vaccinations (PCV13 OR = 3.55, [1.47, 8.54]; PPSV23 OR = 4.92, [1.51, 16.02]). These data suggest that partnerships between primary care physicians and pulmonologists can potentially improve the vaccination rates for patients with COPD.
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Affiliation(s)
| | - Kristina Crothers
- Veterans Affairs Puget Sound and University of Washington, Seattle, WA, USA
| | - Benjamin Rodwin
- Internal Medicine, Yale University School of Medicine, New Haven, CT, USA.,Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
| | - Brett Bade
- Internal Medicine, Yale University School of Medicine, New Haven, CT, USA.,Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
| | - Cynthia Brandt
- Veterans Affairs Connecticut Pain Research, Informatics, Multi-Morbidities, and Education Center, West Haven, CT, USA.,Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Kathleen M Akgün
- Internal Medicine, Yale University School of Medicine, New Haven, CT, USA. .,Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA. .,Veterans Affairs Connecticut Pain Research, Informatics, Multi-Morbidities, and Education Center, West Haven, CT, USA.
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18
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Suissa S. Inhaled Corticosteroid Withdrawal in Chronic Obstructive Pulmonary Disease: Can IMPACT Help? Am J Respir Crit Care Med 2020; 202:1202-1204. [PMID: 32758097 PMCID: PMC7605197 DOI: 10.1164/rccm.202006-2600ed] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Affiliation(s)
- Samy Suissa
- Centre for Clinical Epidemiology, Jewish General Hospital, Montreal, Quebec, Canada.,Department of Epidemiology and Biostatistics and.,Department of Medicine, McGill University, Montreal, Quebec, Canada
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Contoli M, Morandi L, Di Marco F, Carone M. A perspective for chronic obstructive pulmonary disease (COPD) management: six key clinical questions to improve disease treatment. Expert Opin Pharmacother 2020; 22:427-437. [PMID: 33021128 DOI: 10.1080/14656566.2020.1828352] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION In 2011, the GOLD recommendations for the treatment of Chronic Obstructive Pulmonary Disease (COPD) introduced new clinical elements to classify the severity of the disease and to guide pharmacological choice. For the first time in the GOLD documents, treatment decision was no longer guided only by pulmonary function, but by a more complex combination of pulmonary function and clinical aspects. The recent versions of the GOLD recommendations introduce new aspects for the clinicians and pose new question for the management of the disease. In addition, inflammatory biomarkers and blood eosinophil levels, have been considered to guide treatment selection. AREA COVERED The evolution of disease management proposed by the GOLD document opens several areas of debate. A series of roundtable discussions among respiratory physicians took place in Italy to address key clinical questions. Particularly, the role of lung function and the use of biomarkers, the adherence to international guidelines and the possibility to personalize the pharmacological approach in COPD patients have been discussed, summarized and analyzed. EXPERT OPINION The authors believe that the development of a precision medicine approach tailoring the specific treatment for each patient is the goal of COPD management and may be achieved by considering the phenotypic classification of COPD patients.
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Affiliation(s)
- Marco Contoli
- Department of Morphology, Surgery and Experimental Medicine, Università Di Ferrara, Ferrara, Italy
| | - Luca Morandi
- Department of Morphology, Surgery and Experimental Medicine, Università Di Ferrara, Ferrara, Italy
| | - Fabiano Di Marco
- Department of Health Science, Università degli studi di Milano, Respiratory Unit, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Mauro Carone
- Division of Pneumology, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
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Tervonen T, Hawken N, Hanania NA, Martinez FJ, Heidenreich S, Gilbert I. Maintenance inhaler therapy preferences of patients with asthma or chronic obstructive pulmonary disease: a discrete choice experiment. Thorax 2020; 75:735-743. [PMID: 32631932 PMCID: PMC7476258 DOI: 10.1136/thoraxjnl-2019-213974] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 04/17/2020] [Accepted: 05/07/2020] [Indexed: 11/05/2022]
Abstract
BACKGROUND A variety of maintenance inhaler therapies are available to treat asthma and COPD. Patient-centric treatment choices require understanding patient preferences for the alternative therapies. METHODS A self-completed web-based discrete choice experiment was conducted to elicit patient preferences for inhaler device and medication attributes. Selection of attributes was informed by patient focus groups and literature review. RESULTS The discrete choice experiment was completed by 810 patients with asthma and 1147 patients with COPD. Patients with asthma most valued decreasing the onset of action from 30 to 5 min, followed by reducing yearly exacerbations from 3 to 1. Patients with COPD most and equally valued decreasing the onset of action from 30 to 5 min and reducing yearly exacerbations from 3 to 1. Both patients with asthma and patients with COPD were willing to accept an additional exacerbation in exchange for a 15 min decrease in onset of action and a longer onset of action in exchange for a lower risk of adverse effects from inhaled corticosteroids. Patients with asthma and COPD valued once-daily over twice-daily dosing, pressurised inhalers over dry powder inhalers and non-capsule priming over single-use capsules, although these attributes were not valued as highly as faster onset of action or reduced exacerbations. CONCLUSIONS The most important maintenance inhaler attributes for patients with asthma and COPD were fast onset of symptom relief and a lower rate of exacerbations. Concerns about safety of inhaled corticosteroids and device convenience also affected patient preferences but were less important.
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Affiliation(s)
- Tommi Tervonen
- Patient-Centered Research, Evidera, London, UK
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Nicola A Hanania
- Section of Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Fernando J Martinez
- Division of Pulmonary Medicine, Weill-Cornell Medical Center, Cornell University, New York City, New York, USA
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Alter P, Baker JR, Dauletbaev N, Donnelly LE, Pistenmaa C, Schmeck B, Washko G, Vogelmeier CF. Update in Chronic Obstructive Pulmonary Disease 2019. Am J Respir Crit Care Med 2020; 202:348-355. [PMID: 32407642 PMCID: PMC8054880 DOI: 10.1164/rccm.202002-0370up] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Peter Alter
- Department of Medicine, Pulmonary and Critical Care Medicine, Member of the German Center for Lung Research (DZL)
| | - Jonathan R. Baker
- Airway Disease, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Nurlan Dauletbaev
- Department of Medicine, Pulmonary and Critical Care Medicine, Member of the German Center for Lung Research (DZL),Department of Pediatrics, Faculty of Medicine, McGill University, Montreal, Quebec, Canada,Faculty of Medicine and Healthcare, al-Farabi Kazakh National University, Almaty, Kazakhstan; and
| | - Louise E. Donnelly
- Airway Disease, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Carrie Pistenmaa
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Bernd Schmeck
- Department of Medicine, Pulmonary and Critical Care Medicine, Member of the German Center for Lung Research (DZL),Institute for Lung Research, Member of the DZL and of the German Center of Infection Research (DZIF), and,Center for Synthetic Microbiology (SYNMIKRO), Philipps University of Marburg, Marburg, Germany
| | - George Washko
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Claus F. Vogelmeier
- Department of Medicine, Pulmonary and Critical Care Medicine, Member of the German Center for Lung Research (DZL)
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Palli SR, Frazer M, DuCharme M, Buikema AR, Anderson AJ, Franchino-Elder J. Differences in Real-World Health and Economic Outcomes Among Patients with COPD Treated with Combination Tiotropium/Olodaterol Versus Triple Therapy. J Manag Care Spec Pharm 2020; 26:1363-1374. [PMID: 32678719 PMCID: PMC10390943 DOI: 10.18553/jmcp.2020.20159] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The 2018 Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommends combination long-acting muscarinic antagonists/long-acting beta2-agonists (LAMA + LABA) as preferred maintenance therapy for patients with symptomatic chronic obstructive lung disease (COPD) after monotherapy and stepping up to triple therapy (TT; LAMA + LABA + inhaled corticosteroids [ICS]) in case of further exacerbations. Restrictions on TT recommendations have primarily been driven by higher pneumonia risk associated with regular ICS use. Evidence suggests that TT is overprescribed, which may affect economic and clinical outcomes. OBJECTIVE To compare health plan-paid costs, COPD exacerbations, and pneumonia diagnoses among patients newly treated with a LAMA + LABA regimen composed of tiotropium (TIO) + olodaterol (OLO) in a fixed-dose combination inhaler (TIO + OLO) or TT in a U.S. Medicare Advantage Part D insured population. METHODS This retrospective study identified COPD patients aged ≥ 40 years who were initiating TIO + OLO or TT (index regimen) between January 1, 2014, and March 31, 2018, from a national administrative claims database. Continuous insurance coverage for 12 months pretreatment (baseline) and ≥ 30 days posttreatment (follow-up) was required. Patients were followed until the earliest of study end (May 31, 2018), discontinuation of index regimen (≥ 60-day gap in index regimen coverage), switch to a different regimen, or health plan disenrollment. Before analysis of outcomes, TIO + OLO and TT patients were 1:1 propensity score-matched on baseline demographics, comorbidities, COPD medication use, medical resource use, and costs. Cohort differences in post-match outcomes were assessed by Wald Z-test (annualized costs) and Kaplan-Meier method (time to first COPD exacerbation and pneumonia diagnosis). RESULTS After matching, each cohort had 1,454 patients who were well balanced on baseline characteristics. Compared with TT, the TIO + OLO cohort incurred $7,041 (41.1%) lower mean COPD-related total costs ($10,094 vs. $17,135; P < 0.001); cohort differences in the medical component ($3,666 lower for TIO + OLO) were driven by lower mean acute inpatient costs ($3,053 lower for TIO + OLO). Combined mean COPD plus pneumonia-related medical costs were $5,212 (39.0%) lower for TIO + OLO versus TT ($8,209 vs. $13,421; P = 0.006), and total mean all-cause costs were $9,221 (30.4%) lower for TIO + OLO versus TT ($21,062 vs. $30,283; P < 0.001). Kaplan-Meier analysis found longer time to first severe COPD exacerbation (P = 0.020) and first pneumonia diagnosis (P = 0.002) for TIO + OLO versus TT and a lower percentage of TIO + OLO patients experiencing these events (severe COPD exacerbation: 9.0% vs. 16.1%; pneumonia: 14.5% vs. 19.3%). A secondary analysis, which expanded the TIO + OLO cohort to include any LAMA + LABA regimen, had similar findings for all outcomes. CONCLUSIONS COPD patients initiating TIO + OLO incurred lower costs to health plans and experienced fewer COPD exacerbation and pneumonia events relative to TT. These findings provide important real-world economic and clinical insight into the GOLD recommendations for TIO + OLO and LAMA + LABA therapy. The study findings also indicate the continued inconsistency between the recommendations and real-world clinical practices pertaining to TT. DISCLOSURES This study was sponsored by Boehringer Ingelheim Pharmaceuticals, Inc. (BIPI). Palli and Franchino-Elder are employees of BIPI. Frazer, DuCharme, Buikema, and Anderson are employees of Optum, which was contracted by BIPI to conduct this study. The authors received no direct compensation related to the development of the manuscript. BIPI was given the opportunity to review the manuscript for medical and scientific accuracy as well as intellectual property considerations.
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Affiliation(s)
- Swetha R Palli
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, Connecticut
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Fan KG, Mandel J, Agnihotri P, Tai-Seale M. Remote Patient Monitoring Technologies for Predicting Chronic Obstructive Pulmonary Disease Exacerbations: Review and Comparison. JMIR Mhealth Uhealth 2020; 8:e16147. [PMID: 32348262 PMCID: PMC7273236 DOI: 10.2196/16147] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 02/11/2020] [Accepted: 03/23/2020] [Indexed: 12/16/2022] Open
Abstract
Background Chronic obstructive pulmonary disease (COPD) is the third leading cause of death by disease worldwide and has a 30-day readmission rate of 22.6%. In 2015, COPD was added to the Medicare Hospital Readmission Reductions Program. Objective The objective of this paper was to survey the current medical technologies for remote patient monitoring (RPM) tools that forecast COPD exacerbations in order to reduce COPD readmissions. Methods We searched literature and digital health news to find commercially available RPM devices focused on predicting COPD exacerbations. These technologies were reviewed and compared according to four criteria: forecasting ability, cost, ease of use, and appearance. A rating system was developed to facilitate the evaluation process. Results As of June 2019, a list of handheld and hands-free devices was compiled. We compared features and found substantial variations. Devices that ranked higher on all criteria tended to have a high or unlisted price. Commonly mass-marketed devices like the pulse oximeter and spirometer surprisingly fulfilled the least criteria. Conclusions The COPD RPM technologies with most technological promise and compatibility with daily living appear to have high or unlisted prices. Consumers and providers need better access to product information to make informed decisions.
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Affiliation(s)
| | - Jess Mandel
- Division of Pulmonary, Critical Care, and Sleep Medicine, School of Medicine, University of California San Diego, La Jolla, CA, United States
| | - Parag Agnihotri
- University of California San Diego Health Population Health Services Organization, University of California San Diego, La Jolla, CA, United States
| | - Ming Tai-Seale
- Department of Family Medicine and Public Health, University of California San Diego, La Jolla, CA, United States
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Spece LJ, Donovan LM, Griffith MF, Keller T, Feemster LC, Smith NL, Au DH. Initiating Low-Value Inhaled Corticosteroids in an Inception Cohort with Chronic Obstructive Pulmonary Disease. Ann Am Thorac Soc 2020; 17:589-595. [PMID: 31899652 PMCID: PMC7193812 DOI: 10.1513/annalsats.201911-854oc] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 01/03/2020] [Indexed: 01/08/2023] Open
Abstract
Rationale: Decreasing medication overuse represents an opportunity to avoid harm and costs in the era of value-based purchasing. Studies of inhaled corticosteroids (ICS) overuse in chronic obstructive pulmonary disease (COPD) have examined prevalent use. Understanding initiation of low-value ICS among complex patients with COPD may help shape deadoption efforts.Objectives: Examine ICS initiation among a cohort with low exacerbation risk COPD and test for associations with markers of patient and health system complexity.Methods: Between 2012 and 2016, we identified veterans with COPD from 21 centers. Our primary outcome was first prescription of ICS. We used the care assessment needs (CAN) score to assess patient-level complexity as the primary exposure. We used a time-to-event model with time-varying exposures over 1-year follow-up. We tested for effect modification using selected measures of health system complexity.Results: We identified 8,497 patients with COPD without an indication for ICS and did not have baseline use (inception cohort). Follow-up time was four quarters. Patient complexity by a continuous CAN score was associated with new dispensing of ICS (hazard ratio = 1.17 per 10-unit change; 95% confidence interval = 1.13-1.21). This association demonstrated a dose-response when examining quartiles of CAN score. Markers of health system complexity did not modify the association between patient complexity and first use of low-value ICS.Conclusions: Patient complexity may represent a symptom burden that clinicians are attempting to mitigate by initiating ICS. Lack of effect modification by health system complexity may reflect the paucity of structural support and low prioritization for COPD care.
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Affiliation(s)
- Laura J. Spece
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
- Health Services Research and Development, and
| | - Lucas M. Donovan
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
- Health Services Research and Development, and
| | - Matthew F. Griffith
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
- Health Services Research and Development, and
| | - Thomas Keller
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
- Health Services Research and Development, and
| | - Laura C. Feemster
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
- Health Services Research and Development, and
| | - Nicholas L. Smith
- Cardiovascular Health Research Unit, University of Washington, Seattle, Washington
- Epidemiologic Research and Information Center, Department of Veterans Affairs Puget Sound Health Care System, Seattle, Washington; and
- Kaiser Permanente Washington Research Institute, Kaiser Permanente Washington, Seattle, Washington
| | - David H. Au
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
- Health Services Research and Development, and
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25
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Keller T, Spece LJ, Donovan LM, Udris E, Coggeshall SS, Griffith M, Bryant AD, Casaburi R, Cooper JA, Criner GJ, Diaz PT, Fuhlbrigge AL, Gay SE, Kanner RE, Martinez FJ, Panos RJ, Shade D, Sternberg A, Stibolt T, Stoller JK, Tonascia J, Wise R, Yusen RD, Au DH, Feemster LC. Association of Guideline-Recommended COPD Inhaler Regimens With Mortality, Respiratory Exacerbations, and Quality of Life: A Secondary Analysis of the Long-Term Oxygen Treatment Trial. Chest 2020; 158:529-538. [PMID: 32278779 DOI: 10.1016/j.chest.2020.02.073] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 02/04/2020] [Accepted: 02/23/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Although inhaled therapy reduces exacerbations among patients with COPD, the effectiveness of providing inhaled treatment per risk stratification models remains unclear. RESEARCH QUESTION Are inhaled regimens that align with the 2017 Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy associated with clinically important outcomes? STUDY DESIGN AND METHODS We conducted secondary analyses of Long-term Oxygen Treatment Trial (LOTT) data. The trial enrolled patients with COPD with moderate resting or exertional hypoxemia between 2009 and 2015. Our exposure was the patient-reported inhaled regimen at enrollment, categorized as either aligning with, undertreating, or potentially overtreating per the 2017 GOLD strategy. Our primary composite outcome was time to death or first hospitalization for COPD. Additional outcomes included individual components of the composite outcome and time to first exacerbation. We generated multivariable Cox proportional hazard models across strata of GOLD-predicted exacerbation risk (high vs low) to estimate between-group hazard ratios for time to event outcomes. We adjusted models a priori for potential confounders, clustered by site. RESULTS The trial enrolled 738 patients (73.4% men; mean age, 68.8 years). Of the patients, 571 (77.4%) were low risk for future exacerbations. Of the patients, 233 (31.6%) reported regimens aligning with GOLD recommendations; most regimens (54.1%) potentially overtreated. During a 2.3-year median follow-up, 332 patients (44.9%) experienced the composite outcome. We found no difference in time to composite outcome or death among patients reporting regimens aligning with recommendations compared with undertreated patients. Among patients at low risk, potential overtreatment was associated with higher exacerbation risk (hazard ratio, 1.42; 95% CI, 1.09-1.87), whereas inhaled corticosteroid treatment was associated with 64% higher risk of pneumonia (incidence rate ratio, 1.64; 95% CI, 1.01-2.66). INTERPRETATION Among patients with COPD with moderate hypoxemia, we found no difference in clinical outcomes between inhaled regimens aligning with the 2017 GOLD strategy compared with those that were undertreated. These findings suggest the need to reevaluate the effectiveness of risk stratification model-based inhaled treatment strategies.
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Affiliation(s)
- Thomas Keller
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA.
| | - Laura J Spece
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA; Health Services Research & Development Center of Innovation for Veteran-centered and Value-driven Care, VA Puget Sound Healthcare System, Seattle, WA
| | - Lucas M Donovan
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA; Health Services Research & Development Center of Innovation for Veteran-centered and Value-driven Care, VA Puget Sound Healthcare System, Seattle, WA
| | - Edmunds Udris
- Health Services Research & Development Center of Innovation for Veteran-centered and Value-driven Care, VA Puget Sound Healthcare System, Seattle, WA
| | - Scott S Coggeshall
- Health Services Research & Development Center of Innovation for Veteran-centered and Value-driven Care, VA Puget Sound Healthcare System, Seattle, WA
| | - Matthew Griffith
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA; Health Services Research & Development Center of Innovation for Veteran-centered and Value-driven Care, VA Puget Sound Healthcare System, Seattle, WA
| | - Alexander D Bryant
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Richard Casaburi
- Los Angeles Biomedical Research Institute at Harbor - UCLA Medical Center, Torrance, CA
| | - J Allen Cooper
- Birmingham VA Medical Center and the Lung Health Center, University of Alabama Birmingham, Birmingham, AL
| | | | - Philip T Diaz
- 201 Heart Lung Institute, Ohio State University School of Medicine, Columbus, OH
| | | | - Steven E Gay
- University of Michigan School of Medicine, Ann Arbor, MI
| | | | | | - Ralph J Panos
- Cincinnati VA Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH
| | - David Shade
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Alice Sternberg
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Thomas Stibolt
- Kaiser Permanente Center for Health Research, Portland, OR
| | | | - James Tonascia
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Robert Wise
- Johns Hopkins University School of Medicine, Baltimore, MD
| | - Roger D Yusen
- Washington University School of Medicine, Saint Louis, MO
| | - David H Au
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA; Health Services Research & Development Center of Innovation for Veteran-centered and Value-driven Care, VA Puget Sound Healthcare System, Seattle, WA
| | - Laura C Feemster
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA; Health Services Research & Development Center of Innovation for Veteran-centered and Value-driven Care, VA Puget Sound Healthcare System, Seattle, WA
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Xu Q, Laxa SS, Serna O, Sansgiry SS. Medication Use Before and After Hospitalization for Chronic Obstructive Pulmonary Disease in a Cohort of Elderly Patients with a Medicare Advantage Plan. AMERICAN HEALTH & DRUG BENEFITS 2020; 13:32-42. [PMID: 32165997 PMCID: PMC7040953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 11/08/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Several medications, including long-acting bronchodilators (LABDs), are critical to the management of chronic obstructive pulmonary disease (COPD). Clinical guidelines recommend the initiation of an LABD for COPD posthospitalization to prevent exacerbations. COPD can limit a patient's exercise tolerance, mobility, and ability to work. Disease exacerbations resulting from inadequate treatment have contributed to increased medical costs and morbidity. OBJECTIVES To analyze the prescription fills for COPD medications, especially LABDs, before and after COPD-related hospitalization, in elderly patients, and to evaluate factors associated with prescription fills of LABDs after COPD-related hospitalization. METHODS This retrospective cohort study included patients with COPD aged ≥65 years who enrolled in Cigna-HealthSpring Medicare Advantage plans in Texas between 2011 and 2014. The index hospitalization was the first hospitalization with a primary diagnosis of COPD. Based on prescription fills within 180 days of the postindex discharge date, eligible patients were divided into 4 groups, by types of medication used. Prescription fills were compared during the 180-day preindex admission and 180-day postindex discharge. RESULTS Of the 1352 patients included, 12% received LABDs and 26% received any COPD medication. The LABD group versus the no-LABD group and the COPD medication group versus the no-COPD medication group were more likely to have a higher Charlson Comorbidity Index (CCI) score. McNemar's tests indicated that the proportions of patients who filled any COPD medication prescription increased from before to after hospitalization. Overall, 69% of patients did not fill any COPD medication during the study period. Adjusted analysis indicated that patients with a higher CCI score who filled an LABD prescription or at least 1 other COPD medication within 180 days before hospitalization were more likely to fill an LABD prescription after hospitalization; filling an inhaled corticosteroid (ICS) prescription before hospitalization was associated with not filling an LABD prescription after hospitalization. CONCLUSIONS Although filling an LABD and other COPD medications increased after hospitalization, the overall prescription fills for LABDs according to clinical guidelines was low in elderly patients. Patients with COPD who underutilized LABDs for maintenance therapy and relied more on ICSs before hospitalization were less likely to fill a prescription for an LABD after hospitalization. Future studies should evaluate patients' reasons for medication underutilization.
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Affiliation(s)
- Qingqing Xu
- PhD candidate, College of Pharmacy, University of Houston, TX
| | | | - Omar Serna
- Clinical Operations Manager, CareAllies, Houston
| | - Sujit S Sansgiry
- Professor, Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston
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Hillas G, Papaporfyriou A, Dimakou K, Papaioannou AI. Pharmacological treatment of stable COPD: need for a simplified approach. Postgrad Med 2020; 132:126-131. [DOI: 10.1080/00325481.2019.1706996] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- G. Hillas
- 5th Pulmonary Department, “Sotiria” Chest Diseases Hospital, Athens, Greece
| | - A. Papaporfyriou
- 2nd Respiratory Medicine Department, University of Athens, Attikon Hospital, Athens, Greece
| | - K. Dimakou
- 5th Pulmonary Department, “Sotiria” Chest Diseases Hospital, Athens, Greece
| | - A. I. Papaioannou
- 2nd Respiratory Medicine Department, University of Athens, Attikon Hospital, Athens, Greece
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Aligning Prescribing Practices with Chronic Obstructive Pulmonary Disease Guidelines: A Sisyphean Struggle? Ann Am Thorac Soc 2019; 16:187-188. [PMID: 30707064 DOI: 10.1513/annalsats.201811-797ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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29
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Kim TO, Shin HJ, Kim YI, Rhee CK, Lee WY, Lim SY, Ra SW, Jung KS, Yoo KH, Park SJ, Lim SC. Adherence to the GOLD Guideline in COPD Management of South Korea: Findings from KOCOSS Study 2011-2018. Chonnam Med J 2019; 55:47-53. [PMID: 30740340 PMCID: PMC6351324 DOI: 10.4068/cmj.2019.55.1.47] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 12/06/2018] [Accepted: 12/10/2018] [Indexed: 01/28/2023] Open
Abstract
The guidelines for chronic obstructive pulmonary disease (COPD) treatment are important for the management of the disease. However, studies regarding the treatment adherence to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines have been scarce in Korea. Therefore, to examine the adherence to the GOLD guidelines, we examined the patterns of prescribed medication in COPD patients from 2011 to 2018. Patients were classified as having been appropriately and inappropriately treated (overtreatment or undertreatment) for the GOLD group. Appropriate medical therapy was defined as using the first choice or alternative choice drug recommended in the GOLD guidelines. Inappropriate therapy was classified as overtreatment or undertreatment in accordance with the categorization in the GOLD guidelines. According to treatment of 2011 GOLD guidelines, there was inappropriate treatment in 52.3% in group A, 47.3% in group B, 56.3% in group C, and 17.8% in group D. According to treatment of 2017 GOLD guidelines, there was inappropriate treatment in 66.7% in group A, 45.3% in group B, 14.3% in group C, and 24.0% in group D. The common type of inappropriate COPD treatment is overtreatment, with inhaled corticosteroid (ICS) containing regimens. In conclusions, adherence to the GOLD guideline by the pulmonologist in clinical practice is still low in Korea. Therefore, we need better strategies to both optimize the use of the guidelines and adhere to the guidelines as well.
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Affiliation(s)
- Tae-Ok Kim
- Division of Pulmonary Medicine, Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Hong-Joon Shin
- Division of Pulmonary Medicine, Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Yu-Il Kim
- Division of Pulmonary Medicine, Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Chin-Kook Rhee
- Department of Internal Medicine, The Catholic University of Korea, Seoul St. Mary's Hospital, Seoul, Korea
| | - Won-Yeon Lee
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Seong-Yong Lim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung-Won Ra
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine and the Clinical Research Center for Chronic Obstructive Airway Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ki-Suck Jung
- Division of Pulmonary Medicine, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University Medical School, Anyang, Korea
| | - Kwang-Ha Yoo
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Seoung-Ju Park
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Chonbuk National University Medical School, Jeonju, Korea
| | - Sung-Chul Lim
- Division of Pulmonary Medicine, Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
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