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Anzueto A, Rogers S, Donato B, Jones B, Modi K, Olopoenia A, Wise R. Treatment patterns in patients with newly diagnosed COPD in the USA. BMC Pulm Med 2024; 24:395. [PMID: 39153976 PMCID: PMC11330015 DOI: 10.1186/s12890-024-03194-4] [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: 01/23/2024] [Accepted: 07/31/2024] [Indexed: 08/19/2024] Open
Abstract
BACKGROUND Prompt and effective management with maintenance therapy (single or dual bronchodilator therapy) is recommended after the initial diagnosis of chronic obstructive pulmonary disease (COPD) to maintain lung function and prevent exacerbations. Contrary to guideline-based recommendations, most patients are not prescribed maintenance treatment at initial diagnosis. The current study assessed the pharmacologic treatment patterns and outcomes of newly diagnosed patients with COPD in the USA. METHODS This retrospective, noninterventional study used de-identified data from the Inovalon Insights' database (Commercial, Medicaid Managed Care, and Medicare Advantage-insured individuals) between January 1, 2015, and December 31, 2021. The "patient journey" from initial diagnosis was followed over a 4-year period. The primary outcome measure was the number of moderate or severe exacerbations. Secondary outcome measures included the cumulative incidence of exacerbations, mean cumulative count of moderate and severe exacerbations, rates of moderate and severe exacerbations in patients who remained untreated after diagnosis in 12-month time periods for 4 years, sociodemographic and clinical characteristics, and pharmacologic treatment patterns. RESULTS The cohort consisted of 238,158 newly diagnosed patients with COPD (female [52.9%]; mean age 63.8 years). The majority of patients with COPD had Medicaid as their primary insurance (46.2%). Overall, during the 4-year follow-up period, 32.9% of the patients had at least one moderate or severe exacerbation, and 25.8% and 13.8% experienced moderate and severe exacerbations, respectively. At diagnosis, 86.2% of the patients were untreated and most remained untreated by the end of the follow-up (63.8%). Most patients (62.0%) received long-acting beta-agonist (LABA)/inhaled corticosteroids (ICS) as their initial treatment at diagnosis, and LABA/ICS continued to be the most common initial treatment during the 4-year period (64.0% at year 1; 58.0% at year 4). CONCLUSIONS Most patients with COPD were not treated at initial diagnosis and remained untreated during follow-up. Our data highlight a lack of adherence to recommendations for clinical practice.
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Affiliation(s)
- Antonio Anzueto
- South Texas Veterans Healthcare System, Division of Pulmonary Diseases/Critical Care Medicine, University of Texas Health, 111 E 7400 Merton Minter Blvd, San Antonio, TX, 78229, USA.
| | | | | | | | | | | | - Robert Wise
- Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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2
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Klitgaard A, Ibsen R, Hilberg O, Løkke A. Urban-rural and socio-economic differences in inhaled corticosteroid treatment for chronic obstructive pulmonary disease: A nationwide register-based cross-sectional study. Respir Med 2024; 229:107678. [PMID: 38815657 DOI: 10.1016/j.rmed.2024.107678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 05/15/2024] [Accepted: 05/24/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND Urban-rural disparities within chronic obstructive pulmonary disease (COPD) have been documented in USA, but not in Europe. Inhaled corticosteroids (ICS) are widely used in COPD despite strict recommendations. We aimed to investigate urban-rural and socioeconomic differences in ICS treatment for COPD. METHODS A Danish nationwide register-based cross-sectional study. All patients alive on the December 31, 2018 with a J44 ICD-10 diagnosis code (COPD) were included (99,057 patients). Daily average ICS dose was calculated from the accumulated ICS use during 2018 based on redeemed prescriptions. Patients were divided into groups: No ICS, low dose ICS, medium dose ICS, high dose ICS. A multinomial logistic regression model including educational level, co-habitation status, age, and sex was performed with "No ICS" as reference group. RESULTS Compared to capital municipalities, living in other municipality types was associated with an increased probability of receiving medium and high dose ICS treatment, and increasing odds ratios (ORs) were seen with increasing ICS dose (medium dose ICS: ORs between 1.31 (95 % confidence interval (CI) 1.24-1.38) and 1.35 (95%CI 1.28-1.41), high dose ICS: ORs between 1.73 (95%CI 1.59-1.88) and 1.80 (95%CI 1.68-1.92)). Patients had increased probability of receiving ICS treatment if they were female, were co-habiting, or had completed only primary education. CONCLUSION Patients with a hospital-registered COPD diagnosis in non-capital municipalities receive more ICS, and in higher doses, compared to patients in capital municipalities. This is the first study to confirm that such urban-rural differences exist in Europe, and further research on this area is warranted.
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Affiliation(s)
- Allan Klitgaard
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark; Department of Internal Medicine, University Hospital Lillebaelt, Vejle, Denmark.
| | | | - Ole Hilberg
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark; Department of Internal Medicine, University Hospital Lillebaelt, Vejle, Denmark
| | - Anders Løkke
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark; Department of Internal Medicine, University Hospital Lillebaelt, Vejle, Denmark
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3
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Crawford AL, Blakey JD, Ramakrishnan S. The Exacerbation, Not the Patient, Determines Chronic Obstructive Pulmonary Disease Exacerbation Care Seeking. Ann Am Thorac Soc 2024; 21:541-542. [PMID: 38557421 PMCID: PMC10995554 DOI: 10.1513/annalsats.202401-010ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Affiliation(s)
- Alice L Crawford
- Institute for Respiratory Health, University of Western Australia, Perth, Western Australia, Australia; and
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - John D Blakey
- Institute for Respiratory Health, University of Western Australia, Perth, Western Australia, Australia; and
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Sanjay Ramakrishnan
- Institute for Respiratory Health, University of Western Australia, Perth, Western Australia, Australia; and
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
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4
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Alsuwaigh R, Yii A, Loh CH, Xu X, Bahety P, Navarro Rojas AA, Milea D, Tee A. A comparison of GOLD 2019 and 2023 recommendations to contemporaneous real-world inhaler treatment patterns for chronic obstructive pulmonary disease management in Singapore. J Thorac Dis 2024; 16:847-861. [PMID: 38505044 PMCID: PMC10944796 DOI: 10.21037/jtd-22-1769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 09/01/2023] [Indexed: 03/21/2024]
Abstract
Background In 2019 and 2023, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) provided updated strategies for modifying the therapy of patients with chronic obstructive pulmonary disease (COPD) and high exacerbation risk. A key update since the 2019 guidelines recommends considering blood eosinophil count to guide decisions on inhaled corticosteroid (ICS) treatment. To evaluate the potential impact of these updated recommendations, this study aimed to assess how extensively future practice would diverge from contemporaneous prescribing practices at a single center in Singapore, assuming adherence to the 2019 and 2023 GOLD guidelines. Methods Retrospective cohort analysis of the Changi General Hospital COPD data warehouse involving patients aged ≥40 years hospitalized for a COPD exacerbation (October 2018-April 2020) receiving long-acting muscarinic antagonist (LAMA), LAMA plus a long-acting beta2-agonist (LABA), or an ICS plus LABA at admission. The proportion of patients eligible for treatment escalations per GOLD 2019 and 2023 recommendations was calculated. Results In total, 268 patients were included (mean age 73 years; 91% male). At admission, 19%, 59%, and 22% of patients were receiving LAMA, LAMA + LABA, and ICS + LABA, respectively. Overall, 226 patients would have been eligible for treatment escalation per GOLD 2019 or 2023 recommendations; 31 (13.7%) had treatment escalations consistent with GOLD 2019 guidelines and 34 (15%) received treatment escalations consistent with GOLD 2023 guidelines. A total of 205 patients (76.5%) remained on the same treatment regimen at hospital discharge as they were receiving at admission. Lower measured post-bronchodilator forced expiratory volume in 1 second was associated with treatment escalations that would have been GOLD-concordant (P=0.028), as was increased number of emergency department/hospital visits in the last year (P=0.048). Conclusions Compared with real-world clinical practice, a significantly higher proportion of patients may be eligible for treatment escalation under the GOLD 2019 and 2023 eosinophil-directed algorithms.
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Affiliation(s)
- Rayan Alsuwaigh
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore, Singapore
| | - Anthony Yii
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore, Singapore
| | - Chee Hong Loh
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore, Singapore
| | - Xiaomeng Xu
- Value Evidence and Outcomes, GSK, Greater China and Intercontinental, Singapore, Singapore
| | - Priti Bahety
- Medical Affairs, GSK, Greater China and Intercontinental, Singapore, Singapore
| | | | - Dominique Milea
- Value Evidence and Outcomes, GSK, Greater China and Intercontinental, Singapore, Singapore
| | - Augustine Tee
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore, Singapore
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5
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Klitgaard A, Ibsen R, Lykkegaard J, Hilberg O, Løkke A. National Development in the Use of Inhaled Corticosteroid Treatment in Chronic Obstructive Pulmonary Disease: Repeated Cross-Sectional Studies from 1998 to 2018. Biomedicines 2024; 12:372. [PMID: 38397973 PMCID: PMC10886715 DOI: 10.3390/biomedicines12020372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 01/31/2024] [Accepted: 02/01/2024] [Indexed: 02/25/2024] Open
Abstract
Recommendations for the treatment of chronic obstructive pulmonary disease (COPD) have shifted towards a more restrictive use of inhaled corticosteroids (ICS). We aimed to identify the nationwide development over time in the use of ICS treatment in COPD. We conducted a register-based repeated cross-sectional study using Danish nationwide registers. On a yearly basis from 1998 to 2018, we included all patients in Denmark ≥ 40 years of age with an ICD-10 diagnosis of COPD (J44). Accumulated ICS use was calculated for each year based on redeemed prescriptions. Patients were divided into the following groups: No ICS, low-dose ICS, medium-dose ICS, or high-dose ICS. From 1998 to 2018, the yearly proportion of patients without ICS treatment increased (from 50.6% to 57.6%), the proportion of patients on low-dose ICS treatment increased (from 11.3% to 14.9%), and the proportion of patients on high-dose ICS treatment decreased (from 17.0% to 9.4%). We demonstrated a national reduction in the use of ICS treatment in COPD from 1998 to 2018, with an increase in the proportion of patients without ICS and on low-dose ICS treatment and a decrease in the proportion of patients on high-dose ICS treatment.
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Affiliation(s)
- Allan Klitgaard
- Department of Regional Health Research, University of Southern Denmark, 5230 Odense, Denmark; (O.H.); (A.L.)
- Department of Internal Medicine Vejle, University Hospital of Southern Denmark, 7100 Vejle, Denmark
| | | | - Jesper Lykkegaard
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, 6705 Esbjerg, Denmark;
| | - Ole Hilberg
- Department of Regional Health Research, University of Southern Denmark, 5230 Odense, Denmark; (O.H.); (A.L.)
- Department of Internal Medicine Vejle, University Hospital of Southern Denmark, 7100 Vejle, Denmark
| | - Anders Løkke
- Department of Regional Health Research, University of Southern Denmark, 5230 Odense, Denmark; (O.H.); (A.L.)
- Department of Internal Medicine Vejle, University Hospital of Southern Denmark, 7100 Vejle, Denmark
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Miravitlles M, Bhutani M, Hurst JR, Franssen FME, van Boven JFM, Khoo EM, Zhang J, Brunton S, Stolz D, Winders T, Asai K, Scullion JE. Implementing an Evidence-Based COPD Hospital Discharge Protocol: A Narrative Review and Expert Recommendations. Adv Ther 2023; 40:4236-4263. [PMID: 37537515 PMCID: PMC10499689 DOI: 10.1007/s12325-023-02609-8] [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: 05/31/2023] [Accepted: 07/06/2023] [Indexed: 08/05/2023]
Abstract
Discharge bundles, comprising evidence-based practices to be implemented prior to discharge, aim to optimise patient outcomes. They have been recommended to address high readmission rates in patients who have been hospitalised for an exacerbation of chronic obstructive pulmonary disease (COPD). Hospital readmission is associated with increased morbidity and healthcare resource utilisation, contributing substantially to the economic burden of COPD. Previous studies suggest that COPD discharge bundles may result in fewer hospital readmissions, lower risk of mortality and improvement of patient quality of life. However, evidence for their effectiveness is inconsistent, likely owing to variable content and implementation of these bundles. To ensure consistent provision of high-quality care for patients hospitalised with an exacerbation of COPD and reduce readmission rates following discharge, we propose a comprehensive discharge protocol, and provide evidence highlighting the importance of each element of the protocol. We then review care bundles used in COPD and other disease areas to understand how they affect patient outcomes, the barriers to implementing these bundles and what strategies have been used in other disease areas to overcome these barriers. We identified four evidence-based care bundle items for review prior to a patient's discharge from hospital, including (1) smoking cessation and assessment of environmental exposures, (2) treatment optimisation, (3) pulmonary rehabilitation, and (4) continuity of care. Resource constraints, lack of staff engagement and knowledge, and complexity of the COPD population were some of the key barriers inhibiting effective bundle implementation. These barriers can be addressed by applying learnings on successful bundle implementation from other disease areas, such as healthcare practitioner education and audit and feedback. By utilising the relevant implementation strategies, discharge bundles can be more (cost-)effectively delivered to improve patient outcomes, reduce readmission rates and ensure continuity of care for patients who have been discharged from hospital following a COPD exacerbation.
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Affiliation(s)
- Marc Miravitlles
- Pneumology Department, Vall d'Hebron University Hospital/Vall d'Hebron Research Institute (VHIR), Vall d'Hebron Barcelona Hospital Campus, Pg. Vall d'Hebron 119-129, 08035, Barcelona, Spain.
| | - Mohit Bhutani
- Division of Pulmonary Medicine, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - John R Hurst
- UCL Respiratory, University College London, London, UK
| | - Frits M E Franssen
- Department of Respiratory Medicine, Maastricht University Medical Center, Maastricht, Netherlands
| | - Job F M van Boven
- Department of Clinical Pharmacy & Pharmacology, Groningen Research Institute for Asthma and COPD (GRIAC), University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Ee Ming Khoo
- Department of Primary Care Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
- International Primary Care Respiratory Group, Leicester, UK
| | - Jing Zhang
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | | | - Daiana Stolz
- Clinic of Respiratory Medicine and Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tonya Winders
- Global Allergy and Airways Patient Platform, Vienna, Austria
| | - Kazuhisa Asai
- Department of Respiratory Medicine, Osaka Metropolitan University, Osaka, Japan
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7
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Halpin DMG. Clinical Management of COPD in the Real World: Can Studies Reveal Errors in Management and Pathways to Improve Patient Care? Pragmat Obs Res 2023; 14:51-61. [PMID: 37547630 PMCID: PMC10404047 DOI: 10.2147/por.s396830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 07/24/2023] [Indexed: 08/08/2023] Open
Abstract
Real world data comprise information on health care that is derived from multiple sources outside typical clinical research settings. This review focuses on what real world evidence tells us about problems with the diagnosis of chronic obstructive pulmonary disease (COPD), problems with the initial and follow-up pharmacological and non-pharmacological management, problems with the management of exacerbations and problems with palliative care. Data from real world studies show errors in the management of COPD with delays to diagnosis, lack of confirmation of the diagnosis with spirometry, lack of holistic assessment, lack of attention to smoking cessation, variable adherence to management guidelines, delayed implementation of appropriate interventions, under-recognition of patients at higher risk of adverse outcomes, high hospitalisation rates for exacerbations and poor implementation of palliative care. Understanding that these problems exist and considering how and why they occur is fundamental to developing solutions to improve the diagnosis and management of patients with COPD.
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Affiliation(s)
- David M G Halpin
- Department of Respiratory Medicine, University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, UK
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8
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Quint JK, Ariel A, Barnes PJ. Rational use of inhaled corticosteroids for the treatment of COPD. NPJ Prim Care Respir Med 2023; 33:27. [PMID: 37488104 PMCID: PMC10366209 DOI: 10.1038/s41533-023-00347-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 07/04/2023] [Indexed: 07/26/2023] Open
Abstract
Inhaled corticosteroids (ICS) are the mainstay of treatment for asthma, but their role in chronic obstructive pulmonary disease (COPD) is debated. Recent randomised controlled trials (RCTs) conducted in patients with COPD and frequent or severe exacerbations demonstrated a significant reduction (~25%) in exacerbations with ICS in combination with dual bronchodilator therapy (triple therapy). However, the suggestion of a mortality benefit associated with ICS in these trials has since been rejected by the European Medicines Agency and US Food and Drug Administration. Observational evidence from routine clinical practice demonstrates that dual bronchodilation is associated with better clinical outcomes than triple therapy in a broad population of patients with COPD and infrequent exacerbations. This reinforces guideline recommendations that ICS-containing maintenance therapy should be reserved for patients with frequent or severe exacerbations and high blood eosinophils (~10% of the COPD population), or those with concomitant asthma. However, data from routine clinical practice indicate ICS overuse, with up to 50-80% of patients prescribed ICS. Prescription of ICS in patients not fulfilling guideline criteria puts patients at unnecessary risk of pneumonia and other long-term adverse events and also has cost implications, without any clear benefit in disease control. In this article, we review the benefits and risks of ICS use in COPD, drawing on evidence from RCTs and observational studies conducted in primary care. We also provide a practical guide to prescribing ICS, based on the latest global treatment guidelines, to help primary care providers identify patients for whom the benefits of ICS outweigh the risks.
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Affiliation(s)
- Jennifer K Quint
- National Heart and Lung Institute, Imperial College London, London, UK.
| | - Amnon Ariel
- Lung Unit, Emek Medical Center, Afula, Israel
| | - Peter J Barnes
- National Heart and Lung Institute, Imperial College London, London, UK
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9
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Alabi FO, Alkhateeb HA, Zibanayi MT, Garces J, DeBarros KM, Barletti PSB, Garcia K, James RK. The adherence to and utility of the Global Initiative for Chronic Obstructive Lung Disease guidelines for treating COPD among pulmonary specialists: a retrospective analysis. BMC Pulm Med 2023; 23:216. [PMID: 37337205 PMCID: PMC10280890 DOI: 10.1186/s12890-023-02503-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 05/31/2023] [Indexed: 06/21/2023] Open
Abstract
BACKGROUND Despite the evidence-based guidelines promoted by the Global Initiative for Chronic Obstructive Lung Disease (GOLD), the overuse of prescription drugs to manage COPD, particularly inhaled corticosteroids (ICS), remains a persistent challenge. In this real-world study, we evaluated how patients with COPD were divided into ABCD groups based on the 2017 GOLD guidelines, determined the rate of adherence to the GOLD treatment recommendations, described the rate of ICS usage, and determined the rate of triple therapy (TT) prescription. METHODS The charts of 2291 patients diagnosed with COPD were retrospectively analyzed, of which 1438 matched the eligibility criteria. RESULTS The average patient age was 69.6 ± 10.9 years; 52% of patients were female. The average COPD assessment test (CAT) score was 18.3 ± 9.1. The ABCD breakdown was as follows: group A 19.5%, group B 64.1%, group C 1.8%, and group D 14.6%. All groups, except group D, showed discordance in COPD treatment relative to the proposed GOLD guidelines. Only 18.9% of group A and 26% of group B were treated in concordance with the guidelines. TT was primarily used in group D (63.3%) and overused in groups A (30.6%) and B (47.8%). ICS was overused in all groups, particularly in groups A (56.2%) and B (67.3%). CONCLUSION Studies from the last decade have consistently revealed a lack of conformity between what physicians prescribe and what GOLD guidelines recommend. The excessive usage of ICS, which continues despite all the associated adverse effects and the attributable costs, is concerning. The awareness of GOLD guidelines among primary care physicians (PCPs) and respiratory specialists needs to be improved.
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Affiliation(s)
- Fortune O Alabi
- Florida Lung Asthma and Sleep Specialists, Kissimmee, FL, USA.
| | | | | | - Jica Garces
- Florida Lung Asthma and Sleep Specialists, Kissimmee, FL, USA
| | | | | | - Kayla Garcia
- Florida Lung Asthma and Sleep Specialists, Kissimmee, FL, USA
| | - Randall K James
- Florida Lung Asthma and Sleep Specialists, Kissimmee, FL, USA
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10
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Czira A, Purushotham S, Iheanacho I, Rothnie KJ, Compton C, Ismaila AS. Burden of Disease in Patients with Mild or Mild-to-Moderate Chronic Obstructive Pulmonary Disease (Global Initiative for Chronic Obstructive Lung Disease Group A or B): A Systematic Literature Review. Int J Chron Obstruct Pulmon Dis 2023; 18:719-731. [PMID: 37151760 PMCID: PMC10155715 DOI: 10.2147/copd.s394325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 04/06/2023] [Indexed: 05/09/2023] Open
Abstract
Background Patients with mild or mild-to-moderate chronic obstructive pulmonary disease (COPD), defined as Global Initiative for Chronic Obstructive Lung Disease (GOLD) group A/B, are regarded as having a lower risk of experiencing multiple or severe exacerbations compared with patients classified as GOLD group C/D. Current guidelines suggest that patients in GOLD A/B should commence treatment with a bronchodilator; however, some patients within this population who have a higher disease burden may benefit from earlier introduction of dual bronchodilator or inhaled corticosteroid-containing therapies. This study aimed to provide research-based insights into the burden of disease experienced by patients classified as GOLD A/B, and to identify characteristics associated with poorer outcomes. Methods A systematic literature review (SLR) was conducted to identify evidence (burden of disease and prevalence data) relating to the population of interest (patients with COPD classified as GOLD A/B). Results A total of 79 full-text publications and four conference abstracts were included. In general, the rates of moderate and severe exacerbations were higher among patients in GOLD group B than among those in group A. Among patients classified as GOLD A/B, the risk of exacerbation was higher in those with more symptoms (modified Medical Research Council or COPD Assessment Test scales) and more severe airflow limitation (forced expiratory volume in 1 second % predicted). Conclusion Data from this SLR provide clear evidence of a heavier burden of disease for patients in GOLD B, compared with those in GOLD A, and highlight factors associated with worse outcomes for patients in GOLD A/B.
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Affiliation(s)
- Alexandrosz Czira
- Value Evidence and Outcomes, R&D Global Medical, GSK, Brentford, UK
- Correspondence: Alexandrosz Czira, Value Evidence and Outcomes, R&D Global Medical, GSK, 980 Great West Road, Brentford, Middlesex, TW8 9GS, UK, Tel +44 7788 351610, Email
| | | | | | - Kieran J Rothnie
- Value Evidence and Outcomes, R&D Global Medical, GSK, Brentford, UK
| | | | - Afisi S Ismaila
- Value Evidence and Outcomes, GSK, Collegeville, PA, USA
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
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Lapi F, Marconi E, Lombardo FP, Micheletto C, Cricelli C. Variation in costs due to virtual switching from free- to fixed-triple LABA/LAMA/ICS combinations among COPD patients: an analysis using a primary care database. Curr Med Res Opin 2022; 38:1997-2001. [PMID: 36154352 DOI: 10.1080/03007995.2022.2129229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is a condition with a relevant clinical and economic burden. Only 10% to 40% of COPD patients reporting a regular use of respiratory medications, including those who suffered from severe disease being prescribed with triple combination therapy, nominally long-acting beta agonist (LABA), long-acting muscarinic antagonist (LAMA) and inhaled corticosteroid (ICS). The recent market launch of fixed-triple LABA/LAMA/ICS therapy might contribute to improve medications adherence and costs containment, given the use of a single instead of two or three inhalers. Few data are available on costs due to triple therapy prescribed for COPD. In specific, there are no studies providing data on the potential costs saving whether COPD patients exposed to free-triple combination therapy were switched to fixed-triple combination. In this respect, we simulated some scenarios of virtual switching and calculated the related cost savings.
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Affiliation(s)
- Francesco Lapi
- Health Search, Italian College of General Practitioners and Primary Care, Florence, Italy
| | - Ettore Marconi
- Health Search, Italian College of General Practitioners and Primary Care, Florence, Italy
| | | | - Claudio Micheletto
- Cardio-Thoracic Department, Respiratory Unit, Integrated University Hospital, Verona, Italy
| | - Claudio Cricelli
- Italian College of General Practitioners and Primary Care, Florence, Italy
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12
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Bartziokas K, Papaporfyriou A, Hillas G, Papaioannou AI, Loukides S. Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommendations: strengths and concerns for future needs. Postgrad Med 2022; 135:327-333. [PMID: 36226501 DOI: 10.1080/00325481.2022.2135893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Chronic Obstructive Pulmonary Disease (COPD) is already the third leading cause of death worldwide and simultaneously a major cause of morbidity and mortality. Global initiative for Chronic Obstructive Lung Disease (also known as GOLD) committee, has been created in 1997 to increase the awareness regarding the burden of COPD. GOLD recommendations have been contributing to diagnosis, management and therapy of COPD since 2001. Through these years, by reviewing published articles, GOLD aimed to provide state-of-the-art information not only for pulmonologists, but also for non-respiratory physicians, and to encourage research on COPD. From 2011, GOLD annual reports have changed the way of COPD evaluation from based entirely on spirometric parameters to more clinical indices, such as the assessment of symptoms and dyspnea alongside with exacerbations. Moreover, according to recent developments in pathophysiology of COPD, there is a trend in identifying new pre-clinical stages, contributing to prevention and early COPD treatment. In the field of therapeutic algorithms, changes turn to a more personalized approach. However, it is not clear in what extent this personalized disease management would be feasible and the real challenge for current recommendations is to include more patient characteristics such as co-morbidities and multidimensional scores in disease evaluation.
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Affiliation(s)
| | | | - Georgios Hillas
- 5th Respiratory Medicine Department Sotiria Chest Hospital, Athens, Greece
| | | | - Stelios Loukides
- 2nd Respiratory Medicine Department, "Attikon" University Hospital, Athens, Greece
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13
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Strain M, Boehmer K, Usery J. Managing chronic obstructive pulmonary disease in primary care: clinical characteristics of patients receiving inhaled corticosteroids. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2022. [DOI: 10.1002/jppr.1835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Madisyn Strain
- Former PGY2 Ambulatory Care Pharmacy Resident University of Arkansas for Medical Sciences (UAMS) College of Pharmacy Little Rock USA
- Clinical Pharmacy Specialist University of Arkansas for Medical Sciences Little Rock USA
| | - Kaci Boehmer
- PGY2 Ambulatory Care Residency Program Director UAMS College of Pharmacy Little Rock USA
- Assistant Professor, Department of Pharmacy Practice UAMS College of Pharmacy Little Rock USA
- Assistant Professor, Department of Family and Preventative Services UAMS College of Medicine Little Rock USA
- Ambulatory Care Pharmacy Specialist UAMS Family Medical Center Little Rock USA
| | - Justin Usery
- Director of Pharmacy UAMS Ambulatory Care and Regional Programs Little Rock USA
- Internal Medicine Pharmacy Specialist UAMS Internal Medicine Clinic Little Rock USA
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14
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Miravitlles M, González-Torralba F, Represas-Represas C, Pomares X, Márquez-Martín E, González C, Amado C, Forné C, Alonso S, Alcázar B, Barrecheguren M, Jurado Mirete JM, Naval E. Pulmonologists' Opinion on the Use of Inhaled Corticosteroids in Chronic Obstructive Pulmonary Disease Patients in Spain: A Cross-Sectional Survey. Int J Chron Obstruct Pulmon Dis 2022; 17:1577-1587. [PMID: 35855745 PMCID: PMC9288191 DOI: 10.2147/copd.s369118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 07/04/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Identifying the variables that guide decision-making in relation to the use of inhaled corticosteroids (ICS) can contribute to the appropriate use of these drugs. The objective of this study was to identify the clinical variables that physicians consider most relevant for prescribing or withdrawing ICS in COPD. Methods A cross-sectional survey was conducted in Spain from November 2020 to May 2021. Therapeutic decisions on the use of ICS in 11 hypothetical COPD patient profiles were collected using an online survey answered by specialists with experience in the management of patients with COPD. Mixed-effects logistic regression was used to analyze the impact of patients' characteristics in the therapeutic decision for prescribing ICS or proceeding to its withdrawal. Results A total of 74 pulmonologists agreed to collaborate in the survey and answered the questionnaire. The results showed great variability, with only 2 profiles achieving consensus for starting or withdrawing the treatment. The frequency and severity of exacerbations influenced the decision to prescribe ICS in a dose-response fashion (1 exacerbation odds ratio (OR) = 1.86, 95% confidence interval (CI) 1.02 to 3.43, two exacerbations OR = 11.6, 95% CI: 4.47 to 30.2 and three OR = 123, 95% CI: 25 to 601). Similarly, increasing blood eosinophils and history of asthma were associated with ICS use. On the other hand, pneumonia reduced the probability of initiating treatment with ICS (OR = 0.54 [0.29 to 0.98]). Lung function and dyspnea degree did not influence the clinician's therapeutic decision. The results for withdrawal of ICS were similar but in the opposite direction. Conclusion In accordance with guidelines, exacerbations, blood eosinophils and history of asthma or pneumonia are the factors considered by pulmonologist for the indication or withdrawal of ICS. However, the agreement in prescription or withdrawal of ICS when confronted with hypothetical cases is very low, suggesting a great variability in clinical practice.
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Affiliation(s)
- Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), ISCIII, Madrid, Spain
| | | | | | - Xavier Pomares
- CIBER de Enfermedades Respiratorias (CIBERES), ISCIII, Madrid, Spain.,Pneumology Department, Corporació Sanitària Parc Taulí, Sabadell, Spain
| | - Eduardo Márquez-Martín
- CIBER de Enfermedades Respiratorias (CIBERES), ISCIII, Madrid, Spain.,Medical-Surgical Unit for Respiratory Diseases, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Cruz González
- Pneumology Department, Hospital Clínico de Valencia, Valencia, Spain
| | - Carlos Amado
- Pneumology Department, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Carles Forné
- Heorfy Consulting, Lleida, Spain.,Basic Medical Sciences Department, University of Lleida, Lleida, Spain
| | - Soledad Alonso
- Pneumology Department, Hospital Universitario de Torrejón, Torrejón de Ardoz, Spain
| | - Bernardino Alcázar
- Pneumology Department, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Miriam Barrecheguren
- Pneumology Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | | | - Elsa Naval
- Pneumology Department, Hospital Universitario de La Ribera, Alzira, Spain
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15
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Stepped treatment algorithm using budesonide-formoterol for chronic respiratory diseases: A single arm interventional study. PLoS One 2022; 17:e0271178. [PMID: 35816478 PMCID: PMC9273083 DOI: 10.1371/journal.pone.0271178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 06/24/2022] [Indexed: 11/20/2022] Open
Abstract
Background While the safety and efficacy of inhaled budesonide-formoterol, used as-needed for symptoms, has been established for patients with asthma, it has not been trialed in undifferentiated patients with chronic respiratory diseases. We aimed to assess the feasibility of a pragmatic intervention that entails a stepped algorithm using inhaled budesonide-formoterol (dry powder inhaler, 160μg/4.5μg per dose) for patients presenting with chronic respiratory diseases to three rural district hospitals in Hanoi, Vietnam. Methods We recruited patients with evidence of airflow obstruction on spirometry and/or symptoms consistent with asthma. The algorithm consisted of three steps: 1. as-needed inhaled budesonide-formoterol for symptoms, 2. maintenance plus as-needed inhaled budesonide-formoterol, and 3. referral to a higher-level healthcare facility. All participants started at step 1, with escalation to the next step at review visits if there had been exacerbation(s) or inadequate symptom control. Patients were followed for 12 months. Results Among 313 participants who started the treatment algorithm, 47.2% had ≥ 1 episode of acute respiratory symptoms requiring a visit to hospital or clinic and 35.4% were diagnosed with an exacerbation. Twelve months after enrolment, 50.7% still adhered to inhaled budesonide-formoterol at the recommended treatment step. The mean and median number of doses per day was 1.5 (standard deviation 1.2) doses and 1.3 (interquartile range 0.7–2.3) doses, respectively. The proportion of patients taking more than 800μg budesonide per day was 3.8%. Conclusion This novel therapeutic algorithm is feasible for patients with chronic respiratory diseases in a rural setting in Vietnam. Further studies are required to establish the effectiveness, safety and cost-effectiveness of similar approaches in different settings. Trial registration ACTRN12619000554167.
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16
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Sim M, Yii A, Xu X, Bahety P, Loh CH, Navarro Rojas AA, Milea D, Tee A. Characteristics of Patients with Chronic Obstructive Pulmonary Disease Treated with Long-Acting Bronchodilators in a Real-World Setting in Singapore: A Single-Center Observational Study. Int J Chron Obstruct Pulmon Dis 2022; 17:1349-1363. [PMID: 35711173 PMCID: PMC9192350 DOI: 10.2147/copd.s357820] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 05/19/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction There is limited real-world evidence regarding clinical practice for chronic obstructive pulmonary disease (COPD) in Singapore. We compared baseline clinical characteristics and evaluated outcomes in patients with COPD who initiated treatment with either a long-acting muscarinic antagonist (LAMA) or a LAMA and a long-acting β2-agonist (LAMA+LABA). Methods This was a single-center observational study at Changi General Hospital, Singapore. Routine clinical data (hospital visits, case management, lung function, laboratory/imaging results, medication orders) were collected and compiled into a data warehouse. Eligible patients with COPD were ≥40 years old and newly prescribed LAMA or LAMA+LABA during the enrollment period. Patient characteristics in the baseline period (6 months) were compared between treatments. Clinical worsening was measured as a composite endpoint, defined as the first of a change in maintenance treatment class or a moderate-to-severe exacerbation during follow-up (12 months). Results In total, 261 patients were included in the baseline period (LAMA: 73; LAMA+LABA: 188). In the baseline period, patients receiving LAMA+LABA versus LAMA had significantly lower body mass index, higher COPD Assessment Test score and worse lung function, and numerically higher exacerbation history. Prevalence of comorbidities was similar between treatment groups. In follow-up, high rates of clinical worsening were observed regardless of treatment regimen (LAMA: 38/73 [52%]; LAMA+LABA: 86/188 [46%]). Median time-to-clinical worsening was 340 days for the LAMA cohort and the raw median 154 days (interquartile range: 44–225) for the LAMA+LABA cohort. Median medication dispensation rate (0.86; interquartile range: 0.56–1.00) was similar between treatments. Conclusion Patients initiating treatment with LAMA+LABA had more severe COPD than patients prescribed LAMA. The proportion of patients experiencing clinical worsening was similarly high in both cohorts, suggesting that early identification and treatment optimization are necessary.
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Affiliation(s)
- Marcus Sim
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore, Singapore
| | - Anthony Yii
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore, Singapore
| | - Xiaomeng Xu
- Value Evidence & Outcomes, Greater China and Intercontinental, GSK, Singapore, Singapore
| | | | - Chee Hong Loh
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore, Singapore
| | | | - Dominique Milea
- Value Evidence & Outcomes, Greater China and Intercontinental, GSK, Singapore, Singapore
| | - Augustine Tee
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore, Singapore
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17
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Eklöf J, Ingebrigtsen TS, Sørensen R, Saeed MI, Alispahic IA, Sivapalan P, Boel JB, Bangsborg J, Ostergaard C, Dessau RB, Jensen US, Hansen EF, Lapperre TS, Meteran H, Wilcke T, Seersholm N, Jensen JUS. Use of inhaled corticosteroids and risk of acquiring Pseudomonas aeruginosa in patients with chronic obstructive pulmonary disease. Thorax 2022; 77:573-580. [PMID: 34446524 PMCID: PMC9120392 DOI: 10.1136/thoraxjnl-2021-217160] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 07/29/2021] [Indexed: 12/02/2022]
Abstract
BACKGROUND Inhaled corticosteroids (ICS) are commonly used to treat COPD and are associated with increased risk of pneumonia. The aim of this study was to assess if accumulated use of ICS is associated with a dose-dependent risk of a positive airway culture with Pseudomonas aeruginosa in patients with COPD. METHODS We conducted a multiregional epidemiological cohort study including Danish COPD patients followed in outpatient clinics during 2010-2017. ICS use was categorised based on accumulated prescriptions redeemed 365 days prior to cohort entry. Cox proportional hazard regression model was used to estimate the risk of acquiring P. aeruginosa. Propensity score matched models were used as sensitivity analyses. RESULTS A total of 21 408 patients were included in the study, of which 763 (3.6%) acquired P. aeruginosa during follow-up. ICS use was associated with a dose-dependent risk of P. aeruginosa (low ICS dose: HR 1.38, 95% CI 1.03 to 1.84, p=0.03; moderate ICS dose: HR 2.16, 95% CI 1.63 to 2.85, p<0.0001; high ICS dose: HR 3.58, 95% CI 2.75 to 4.65, p<0.0001; reference: no ICS use). A propensity matched model confirmed the results (high ICS dose compared with no/low/moderate ICS dose: HR 2.05, 95% CI 1.76 to 2.39, p p<0.0001). CONCLUSION Use of ICS in patients with COPD followed in Danish outpatient clinics was associated with a substantially increased and dose-dependent risk of acquiring P. aeruginosa. Caution should be taken when administering high doses of ICS in severely ill patients with COPD. These results should be confirmed in comparable cohorts and other settings.
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Affiliation(s)
- Josefin Eklöf
- Department of Internal Medicine, Section of Respiratory Medicine, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | | | - Rikke Sørensen
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Mohamad Isam Saeed
- Department of Internal Medicine, Section of Respiratory Medicine, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Imane Achir Alispahic
- Department of Internal Medicine, Section of Respiratory Medicine, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Pradeesh Sivapalan
- Department of Internal Medicine, Section of Respiratory Medicine, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
- Department of Internal Medicine, Zealand Hospital, University of Copenhagen, Roskilde, Denmark
| | - Jonas Bredtoft Boel
- Department of Clinical Microbiology, Herlev Hospital, University of Copenhagen, Herlev, Denmark
| | - Jette Bangsborg
- Department of Clinical Microbiology, Herlev Hospital, University of Copenhagen, Herlev, Denmark
| | - Christian Ostergaard
- Department of Clinical Microbiology, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
| | - Ram Benny Dessau
- Department of Clinical Microbiology, Slagelse Hospital, Slagelse, Denmark
| | - Ulrich Stab Jensen
- Department of Clinical Microbiology, Slagelse Hospital, Slagelse, Denmark
| | - Ejvind Frausing Hansen
- Department of Respiratory Medicine, Amager and Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
| | - Therese Sophie Lapperre
- Department of Respiratory Medicine, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Howraman Meteran
- Department of Internal Medicine, Section of Respiratory Medicine, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Torgny Wilcke
- Department of Internal Medicine, Section of Respiratory Medicine, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Niels Seersholm
- Department of Internal Medicine, Section of Respiratory Medicine, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Jens-Ulrik Stæhr Jensen
- Department of Internal Medicine, Section of Respiratory Medicine, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
- Department of Clinical Medicine, University of Copenhagen Faculty of Health and Medical Sciences, Copenhagen, Denmark
- PERSIMUNE&CHIP: Department of Infectious Diseases, Rigshospitalet, Copenhagen, Denmark
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18
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Cazzola M, Ora J, Calzetta L, Rogliani P, Matera MG. Advances in inhaled corticosteroids for the treatment of chronic obstructive pulmonary disease: what is their value today? Expert Opin Pharmacother 2022; 23:917-927. [PMID: 35575510 DOI: 10.1080/14656566.2022.2076592] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION As of today, there is still a need to determine which COPD patients may benefit from ICS therapy, whether ICSs are useful in COPD patients without chronic bronchitis, and whether long-acting bronchodilators can reduce the risk of exacerbations in frequent exacerbators even if ICSs are not used, and whether combination therapy including ICSs is helpful in infrequent exacerbators to optimise the use of ICSs in COPD. Nevertheless, in recent years, a fair amount of evidence has been produced that, at least in part, can help define the role of ICSs in COPD better. AREAS COVERED Herein, the authors provide an overview of current use of ICS in COPD and discuss their value to the current treatment armamentarium. The article includes discussion of which patients will benefit best from the use of ICSs, their potential uses and adverse effects. EXPERT OPINION There is growing agreement on why, in whom, and when ICS therapy can be used in COPD, although the consensus is still lacking because of the heterogeneity of COPD. The use of blood eosinophil counts (BECs) is only helpful in T2 inflammation, while there is a lack of biomarkers indicating the presence of T1 and T17 immunity, which is poorly responsive to ICS. Identifying ICS-sensitive endotypes using specific biomarkers that have yet to be identified and validated is likely to demonstrate that ICSs can influence the natural course of COPD in at least a subset of patients.
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Affiliation(s)
- Mario Cazzola
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Josuel Ora
- Unit of Respiratory Medicine, "Tor Vergata" Hospital Foundation, Rome, Italy
| | - Luigino Calzetta
- Unit of Respiratory Diseases and Lung Function, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Paola Rogliani
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy.,Unit of Respiratory Medicine, "Tor Vergata" Hospital Foundation, Rome, Italy
| | - Maria Gabriella Matera
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
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19
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Cross AJ, Thomas D, Liang J, Abramson MJ, George J, Zairina E. Educational interventions for health professionals managing chronic obstructive pulmonary disease in primary care. Cochrane Database Syst Rev 2022; 5:CD012652. [PMID: 35514131 PMCID: PMC9073270 DOI: 10.1002/14651858.cd012652.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is a common, preventable and treatable health condition. COPD is associated with substantial burden on morbidity, mortality and healthcare resources. OBJECTIVES To review existing evidence for educational interventions delivered to health professionals managing COPD in the primary care setting. SEARCH METHODS We searched the Cochrane Airways Trials Register from inception to May 2021. The Register includes records from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Allied and Complementary Medicine Database (AMED) and PsycINFO. We also searched online trial registries and reference lists of included studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) and cluster-RCTs. Eligible studies tested educational interventions aimed at any health professionals involved in the management of COPD in primary care. Educational interventions were defined as interventions aimed at upskilling, improving or refreshing existing knowledge of health professionals in the diagnosis and management of COPD. DATA COLLECTION AND ANALYSIS Two review authors independently reviewed abstracts and full texts of eligible studies, extracted data and assessed the risk of bias of included studies. We conducted meta-analyses where possible and used random-effects models to yield summary estimates of effect (mean differences (MDs) with 95% confidence intervals (CIs)). We performed narrative synthesis when meta-analysis was not possible. We assessed the overall certainty of evidence for each outcome using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). Primary outcomes were: 1) proportion of COPD diagnoses confirmed with spirometry; 2) proportion of patients with COPD referred to, participating in or completing pulmonary rehabilitation; and 3) proportion of patients with COPD prescribed respiratory medication consistent with guideline recommendations. MAIN RESULTS We identified 38 studies(22 cluster-RCTs and 16 RCTs) involving 4936 health professionals (reported in 19/38 studies) and 71,085 patient participants (reported in 25/38 studies). Thirty-six included studies evaluated interventions versus usual care; seven studies also reported a comparison between two or more interventions as part of a three- to five-arm RCT design. A range of simple to complex interventions were used across the studies, with common intervention features including education provided to health professionals via training sessions, workshops or online modules (31 studies), provision of practice support tools, tool kits and/or algorithms (10 studies), provision of guidelines (nine studies) and training on spirometry (five studies). Health professionals targeted by the interventions were most commonly general practitioners alone (20 studies) or in combination with nurses or allied health professionals (eight studies), and the majority of studies were conducted in general practice clinics. We identified performance bias as high risk for 33 studies. We also noted risk of selection, detection, attrition and reporting biases, although to a varying extent across studies. The evidence of efficacy was equivocal for all the three primary endpoints evaluated: 1) proportion of COPD diagnoses confirmed with spirometry (of the four studies that reported this outcome, two supported the intervention); 2) proportion of patients with COPD who are referred to, participate in or complete pulmonary rehabilitation (of the four studies that reported this outcome, two supported the intervention); and 3) proportion of patients with COPD prescribed respiratory medications consistent with guideline recommendations (12 studies reported this outcome, the majority evaluated multiple drug classes and reported a mixed effect). Additionally, the low quality of evidence and potential risk of bias make the interpretation more difficult. Moderate-quality evidence (downgraded due to risk of bias concerns) suggests that educational interventions for health professionals probably improve the proportion of patients with COPD vaccinated against influenza (three studies) and probably have little impact on the proportion of patients vaccinated against pneumococcal infection (two studies). Low-quality evidence suggests that educational interventions for health professionals may have little or no impact on the frequency of COPD exacerbations (10 studies). There was a high degree of heterogeneity in the reporting of health-related quality of life (HRQoL). Low-quality evidence suggests that educational interventions for health professionals may have little or no impact on HRQoL overall, and when using the COPD-specific HRQoL instrument, the St George's Respiratory Questionnaire (at six months MD 0.87, 95% CI -2.51 to 4.26; 2 studies, 406 participants, and at 12 months MD -0.43, 95% CI -1.52 to 0.67, 4 studies, 1646 participants; reduction in score indicates better health). Moderate-quality evidence suggests that educational interventions for health professionals may improve patient satisfaction with care (one study). We identified no studies that reported adverse outcomes. AUTHORS' CONCLUSIONS The evidence of efficacy was equivocal for educational interventions for health professionals in primary care on the proportion of COPD diagnoses confirmed with spirometry, the proportion of patients with COPD who participate in pulmonary rehabilitation, and the proportion of patients prescribed guideline-recommended COPD respiratory medications. Educational interventions for health professionals may improve influenza vaccination rates among patients with COPD and patient satisfaction with care. The quality of evidence for most outcomes was low or very low due to heterogeneity and methodological limitations of the studies included in the review, which means that there is uncertainty about the benefits of any currently published educational interventions for healthcare professionals to improve COPD management in primary care. Further well-designed RCTs are needed to investigate the effects of educational interventions delivered to health professionals managing COPD in the primary care setting.
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Affiliation(s)
- Amanda J Cross
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia
| | - Dennis Thomas
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia
| | - Jenifer Liang
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia
| | - Michael J Abramson
- School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia
| | - Johnson George
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia
| | - Elida Zairina
- Department of Pharmacy Practice, Faculty of Pharmacy, Universitas Airlangga, Surabaya, Indonesia
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20
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Vogelmeier CF, Worth H, Buhl R, Criée CP, Gückel E, Kardos P. Impact of switching from triple therapy to dual bronchodilation in COPD: the DACCORD ‘real world’ study. Respir Res 2022; 23:109. [PMID: 35501806 PMCID: PMC9059416 DOI: 10.1186/s12931-022-02037-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 04/13/2022] [Indexed: 11/10/2022] Open
Abstract
Introduction Chronic obstructive pulmonary disease (COPD) guidelines recommend reserving triple therapy of inhaled corticosteroid (ICS), long-acting β2-agonist (LABA) and long-acting muscarinic antagonist (LAMA) for patients with exacerbations despite dual therapy. However, many patients receive triple therapy without a clear indication. For these patients, it would be useful to know whether ICS can be withdrawn. Methods DACCORD was a longitudinal, non-interventional ‘real-world’ study in three cohorts. This manuscript describes the results of Cohort 3, which recruited patients with COPD who had received triple therapy for ≥ 6 months. Prior to entry, each patient’s physician decided to continue triple therapy, or switch to a LABA/LAMA; patients were then followed for 12 months, with exacerbations and COPD Assessment Test (CAT) data recorded every 3 months. The primary endpoint was the time until COPD worsening, defined as the occurrence of a moderate/severe exacerbation or clinically relevant CAT worsening. Results Of the 1192 patients recruited into the study, 967 completed the end-of-study visit and ≥ 2 of the three interim visits, 292 and 675 receiving LABA/LAMA and triple therapy, respectively. Most baseline demographics were similar between the two groups. A lower proportion of patients in the LABA/LAMA group had COPD worsening than with triple therapy (32.5% vs 55.7% at 12 months), with the time to worsening extended in the LABA/LAMA group (hazard ratio 2.004, p < 0.001). In addition, a significantly lower proportion of patients in the LABA/LAMA group exacerbated (18.5% vs 28.7%; p < 0.001), accompanied by a greater improvement from baseline in CAT total score. Overall, fewer patients in the LABA/LAMA group reported adverse events than in the triple therapy group (12.9% vs 15.1%). Conclusions These results suggest that in a real world setting physicians are able to identify patients who can be ‘stepped down’ from triple therapy to LABA/LAMA. Following step down, there was no overall decline in COPD—indeed, some patients had better outcomes.
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21
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de Jong C, van Boven JFM, de Boer MR, Kocks JWH, Berger MY, van der Molen T. Improved health status of severe COPD patients after being included in an integrated primary care service: A prospective cohort study. Eur J Gen Pract 2022; 28:66-74. [PMID: 35410567 PMCID: PMC9009918 DOI: 10.1080/13814788.2022.2059070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is a prevalent lung disease. It is assumed that severe patients will receive better treatment in specialised care centres but the prevalence of severe COPD in primary care is high. Integrated primary care services combine input from several sources and advice from pulmonologists to provide general practitioners with support needed to improve diagnosis and treatment of patients with COPD. OBJECTIVES To evaluate patient-reported outcomes and costs of managing patients classified as GOLD D in an integrated primary care service over 12 months. METHODS Patients were included in this 1-year prospective cohort study if they met the 2014 GOLD D criteria, were aged ≥ 40 years and gave written informed consent for this study. Recruitment took place through the patients' general practitioners. The primary outcome was health status, assessed with the Clinical COPD Questionnaire (CCQ) and COPD Assessment Test (CAT). Secondary outcomes included self-reported exacerbations, quality-adjusted life years and health(care)-related costs. RESULTS Forty-nine patients were included. At baseline, the mean CAT score was 15.9 and the median CCQ score was 1.7. After 12 months, scores had improved by 2.3 (95% confidence interval, 0.8-3.7) and 0.4 (95% confidence interval, 0.2-0.7), respectively. Percentage of patients with ≥2 exacerbations in the past 12 months also decreased from baseline (77.6%) to 12 months (16.7%). Changes in mean quarterly costs were small. CONCLUSION An integrated service for COPD based in primary care may improve the health status of patients with a large burden of disease while not increasing health care costs.
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Affiliation(s)
- Corina de Jong
- Department of General Practice & Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Job F M van Boven
- Groningen Research Institute for Asthma and COPD (GRIAC), Groningen, The Netherlands.,Department of Clinical Pharmacy & Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Michiel R de Boer
- Department of General Practice & Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Janwillem W H Kocks
- Groningen Research Institute for Asthma and COPD (GRIAC), Groningen, The Netherlands.,General Practitioners Research Institute, Groningen, The Netherlands.,Observational and Pragmatic Research Institute, Singapore, Singapore
| | - Marjolein Y Berger
- Department of General Practice & Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Thys van der Molen
- Department of General Practice & Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD (GRIAC), Groningen, The Netherlands
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22
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Mannino D, Siddall J, Small M, Haq A, Stiegler M, Bogart M. Treatment Patterns for Chronic Obstructive Pulmonary Disease (COPD) in the United States: Results from an Observational Cross-Sectional Physician and Patient Survey. Int J Chron Obstruct Pulmon Dis 2022; 17:749-761. [PMID: 35418752 PMCID: PMC8995154 DOI: 10.2147/copd.s340794] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 02/28/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose There is a high prevalence of chronic obstructive pulmonary disease (COPD) in the United States (US). Although guidelines are available for the treatment of COPD, evidence suggests that management of COPD in clinical practice is not always aligned with this guidance. This study aimed to further understand the current use of COPD maintenance medication in the US. Patients and Methods This study was an analysis of data from the Adelphi Respiratory Disease Specific Programme (DSP™) 2019. Point-in-time data were collected from participating US physicians and their COPD patients. Physicians were either primary care physicians (PCPs) or pulmonologists, with a minimum workload of ≥3 COPD patients per month. Patients were aged ≥18 years with a physician-confirmed diagnosis of COPD. Results In total, 171 physicians completed the survey (92 PCPs and 79 pulmonologists). Mean patient age was 66.4 years, 45% were female, with moderate COPD in 49.4% of patients and severe/very severe in 19.3%. Pulmonologists more frequently prescribed dual bronchodilation and triple therapy than PCPs, whereas inhaled corticosteroid/long-acting β2-agonist was more frequently prescribed by PCPs than pulmonologists. For both physician types, the most common reason for prescribing their patients’ current treatment was 24-hour symptom relief. The majority of PCPs (70.1%) and pulmonologists (71.9%) reported referring to COPD guidelines when making treatment decisions. Conclusion Prescribing patterns for COPD patients were found to differ between PCPs and pulmonologists. Improved physician understanding of how to tailor treatment for each patient, based on current symptoms and exacerbation risk, could help optimize patient care in COPD.
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Affiliation(s)
- David Mannino
- Department of Medicine, University of Kentucky, Lexington, KY, USA
| | - James Siddall
- Respiratory DSP Franchise, Adelphi Real World, Bollington, UK
| | - Mark Small
- Respiratory DSP Franchise, Adelphi Real World, Bollington, UK
| | - Adam Haq
- Respiratory DSP Franchise, Adelphi Real World, Bollington, UK
| | - Marjorie Stiegler
- US Value Evidence and Outcomes, GlaxoSmithKline plc, Durham, NC, USA
| | - Michael Bogart
- US Value Evidence and Outcomes, GlaxoSmithKline plc, Durham, NC, USA
- Correspondence: Michael Bogart, US Value Evidence and Outcomes, GlaxoSmithKline plc, 5 Moore Dr, Research Triangle Park, Durham, NC, USA, Tel +19198897413, Email
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Miravitlles M, Roman-Rodríguez M, Ribera X, Ritz J, Izquierdo JL. Inhaled Corticosteroid Use Among COPD Patients in Primary Care in Spain. Int J Chron Obstruct Pulmon Dis 2022; 17:245-258. [PMID: 35115771 PMCID: PMC8800566 DOI: 10.2147/copd.s342220] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 01/06/2022] [Indexed: 12/03/2022] Open
Abstract
Purpose Inhaled corticosteroids (ICS) are frequently used to treat chronic obstructive pulmonary disease (COPD) outside the current recommendations. Our aim was to describe ICS use in COPD patients and to identify factors associated with ICS use among COPD patients treated within primary care in Spain. Patients and Methods This was a cross-sectional, non-interventional and multicenter study of patients with COPD treated in primary care. Patient characteristics and exacerbations were described in terms of ICS use among the overall cohort, and among those with spirometry confirmed COPD (post-bronchodilator forced expiratory volume in 1 second [FEV1]/forced vital capacity [FVC] ratio <70%). Multivariable logistic regression was used to identify factors associated with ICS use. Results A total of 901 patients were included, of which 47.9% (n = 432) were treated with ICS. A total of 240 patients (26.6%) experienced moderate/severe exacerbations in the prior year, while 309 (34.3%) during the previous two years. History of asthma totaled 11.6% (n = 105). The most frequent phenotype was non-exacerbator (51.6%), and the proportion of patient with moderate or severe exacerbations was significantly higher among ICS treated patients compared to non-treated: 37.5% versus 16.6% during the previous year (p < 0.001), and 46.8% versus 22.8% during the previous 2-years (p < 0.001), respectively. Patient characteristics were similar among spirometry confirmed patients and the overall population. Factors significantly associated with ICS use were a history of asthma (OR = 4.39, 95% CI: 2.67–7.26), the presence of moderate or severe exacerbations in the last year (OR = 2.52, 95% CI: 1.81–3.49), followed by higher mMRC and higher CAT score. Conclusion Nearly half of patients in primary care in Spain are treated with ICS, despite most of them being non-exacerbators. History of asthma, exacerbations, and worse dyspnea and CAT scores are associated with ICS use.
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Affiliation(s)
- Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d´Hebron/Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
- Correspondence: Marc Miravitlles, Pneumology Department, Hospital Universitari Vall d’Hebron, P. Vall d’Hebron 119-129, Barcelona, ES–08035, Spain, Email
| | - Miguel Roman-Rodríguez
- Centro de Salud Dra. Teresa Pique, Mallorca, Spain
- Instituto de Investigación Sanitaria de las Islas Baleares (IdISBa), Mallorca, Spain
| | - Xavier Ribera
- Boehringer Ingelheim España, Sant Cugat del Vallés, Barcelona, Spain
| | - John Ritz
- Syneos Health - Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, CT, USA
| | - José Luis Izquierdo
- Department of Medicine and Medical Specialties, Universidad de Alcalá, Madrid, Spain
- Pneumology Department, Hospital Universitario de Guadalajara, Guadalajara, Spain
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Braido F, Corsico AG, Paleari D, Piraino A, Cavalieri L, Scichilone N. Why small particle fixed dose triple therapy? An excursus from COPD pathology to pharmacological treatment evolution. Ther Adv Respir Dis 2022; 16:17534666211066063. [PMID: 35044875 PMCID: PMC8796083 DOI: 10.1177/17534666211066063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 10/20/2021] [Indexed: 11/17/2022] Open
Abstract
Although bronchodilators are the cornerstone in chronic obstructive pulmonary disease (COPD) therapy, the treatment with a single-agent bronchodilator may not provide adequate symptoms control in COPD. The combination of drugs with different mechanisms of action may be more effective in inducing bronchodilation and preventing exacerbations, with a lower risk of side-effects in comparison with the increase of the dose of a single molecule. Several studies comparing the triple therapy with the association of long-acting ß2 agonist (LABA)/inhaled corticosteroid (ICS) or long-acting muscarinic antagonist (LAMA)/LABA reported improvement of lung function and quality of life. A significant reduction in moderate/severe exacerbations has been observed with a fixed triple combination of beclometasone dipropionate (BDP), formoterol fumarate (FF) and glycopyrronium (G) in a single inhaler. The TRILOGY, TRINITY and TRIBUTE studies have provided confirming evidence for a clinical benefit of triple therapy over ICS/LABA combination treatment, LAMA monotherapy and LABA/LAMA combination, with prevention of exacerbations being a key finding. A pooled post hoc analysis of the published clinical studies involving BDP/FF/G fixed combination demonstrated a reduction in fatal events in patients treated with ICS-containing medications, with a trend of statistical significance [hazard ratio = 0.72, 95% confidence interval (CI) 0.50-1.02, p = 0.066], that becomes significant if we consider reduction in fatal events for non-respiratory reasons (hazard ratio = 0.65, 95% CI 0.43-0.97, p = 0.037). In conclusion, a fixed combination of more drugs in a single inhaler can improve long-term adherence to the therapy, reducing the risk of exacerbations and hospital resources utilization. The twice a day administration may provide a better coverage of night, particularly in COPD patients who are highly symptomatic. The inhaled extrafine formulation that allows drug deposition in both large and small - peripheral - airways, is the value added.
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Affiliation(s)
- Fulvio Braido
- Associate Professor of Respiratory Medicine University of Genoa Head of Respiratory Unit for continuity of care IRCCS Ospedale Policlinico San Martino - Genova
| | - Angelo G. Corsico
- Division of Respiratory Diseases, Foundation IRCCS Policlinico San Matteo, University of Pavia, Pavia 27100, Italy
| | - Davide Paleari
- Medical Affairs, Chiesi Italy. Chiesi Farmaceutici S.p.A. Parma, Italy
| | - Alessio Piraino
- Medical Affairs, Chiesi Italy. Chiesi Farmaceutici S.p.A. Parma, Italy
| | - Luca Cavalieri
- Medical Affairs, Chiesi Italy. Chiesi Farmaceutici S.p.A. Parma, Italy
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25
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Singh D, Holmes S, Adams C, Bafadhel M, Hurst JR. Overcoming Therapeutic Inertia to Reduce the Risk of COPD Exacerbations: Four Action Points for Healthcare Professionals. Int J Chron Obstruct Pulmon Dis 2021; 16:3009-3016. [PMID: 34754186 PMCID: PMC8570921 DOI: 10.2147/copd.s329316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 10/18/2021] [Indexed: 12/26/2022] Open
Abstract
Background Therapeutic inertia, defined as failure to escalate or initiate adequate therapy when treatment goals are not met, contributes to poor management of COPD exacerbations. Methods A multidisciplinary panel of five expert clinicians actively managing COPD and representative of UK practice developed action points to reduce exacerbation risk, based on evidence, clinical expertise, and experience. The action points are applicable despite changing circumstances (eg, virtual clinics). The panel agreed areas where further evidence is needed. Results The four action points were (1) an experienced HCP, such as a GP or member of the multi-professional COPD team should review patients within one month of every exacerbation that requires oral steroids, antibiotics, or hospitalization to address modifiable risk factors, optimize non-pharmacological measures, and evaluate pharmacological therapy. (2) Presenting to hospital with an exacerbation defines an important window of opportunity to reduce the risk of further exacerbations. Follow-up by a GP, or member of the multi-professional specialist COPD team within one month of discharge with a full management review and appropriate escalation of pharmacological treatment is essential. (3) Healthcare professionals (HCPs) in all healthcare settings should be able to recognize COPD exacerbations, refer as appropriate and document the episode accurately in medical records across service boundaries. HCPs should support patients to recognize and report exacerbations. (4) HCPs should intervene proactively based on risk assessments, disease activity and any treatable traits at or as soon as possible after diagnosis and annually thereafter. Delivering these action points needs coordinated action with policymakers, funders, and service providers. Conclusion These action points should be a fundamental part of clinical practice to determine if a change in management is necessary to reduce the risk of exacerbations. Policymakers should use these action points to develop systems and initiatives that reduce the risk of further exacerbations.
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Affiliation(s)
- Dave Singh
- Medicines Evaluation Unit, University of Manchester, Manchester University NHS Foundation Hospitals Trust, Manchester, UK
| | | | - Claire Adams
- Tees Valley Clinical Commissioning Group, Middlesbrough, UK
| | - Mona Bafadhel
- Nuffield Department Clinical Medicine, University of Oxford, Oxford, UK
| | - John R Hurst
- UCL Respiratory, University College London, London, UK
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26
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Tomaich A, Klatt S, Nagy MW. Narrative Literature Review Guided Approach of Inhaled Corticosteroid de-escalation in Chronic Obstructive Pulmonary Disease. J Pharm Pract 2021; 36:628-639. [PMID: 34697964 DOI: 10.1177/08971900211053771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To review the 2020 Global Initiative for Chronic Obstructive Lung Disease (GOLD) report recommendations and create an algorithm to assist clinicians in determining which chronic obstructive pulmonary disease (COPD) patients qualify for inhaled corticosteroid (ICS) de-escalation. Data Sources: A literature search of MEDLINE/PubMed from 2002 to August 2021 was conducted using the search terms inhaled corticosteroids, chronic obstructive pulmonary disease, and de-escalation and review of the reference lists of identified articles for pertinent citations. STUDY SELECTION AND DATA EXTRACTION Relevant studies and articles were included if they focused on the utilization of ICS in COPD. DATA SYNTHESIS The 2020 GOLD report only recommends triple therapy with ICS, long acting beta agonists, and long acting muscarinic antagonists for patients with frequent exacerbations, frequent hospitalizations, or elevated blood eosinophil counts. Despite this clear framework, patients are prescribed ICS without these characteristics. Available evidence suggests that these patients can be de-escalated from ICS therapy without concern for worsening lung function or exacerbations. Relevance to Patient Care and Clinical Practice: Patients with COPD may be experiencing more risk than benefit on ICS therapy. Clinicians should be knowledgeable on how to evaluate patient therapy for appropriateness and know how to safely deprescribe ICS given their limited efficacy in many COPD patients. CONCLUSION There remains no specific guidance on how to de-escalate patients off an ICS when the therapy is not indicated. Use of clinical evidence with stepwise algorithms can be models to approach de-escalation of ICS in patients with COPD.
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Affiliation(s)
- Anamarie Tomaich
- Medical College of Wisconsin School of Pharmacy, Milwaukee WI, USA.,Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee WI, USA
| | - Shawnee Klatt
- Medical College of Wisconsin School of Pharmacy, Milwaukee WI, USA.,Ascension St Joseph Hospital, Milwaukee WI, USA
| | - Michael W Nagy
- Medical College of Wisconsin School of Pharmacy, Milwaukee WI, USA.,Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee WI, USA
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27
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Sansbury LB, Wood RP, Anley GA, Nam Y, Ismaila AS. Quantifying the Economic Impact of Delayed Multiple-Inhaler Triple Therapy Initiation in Patients with COPD: A Retrospective Cohort Study of Linked Electronic Medical Record and Hospital Administrative Data in England. Int J Chron Obstruct Pulmon Dis 2021; 16:2795-2808. [PMID: 34675504 PMCID: PMC8517427 DOI: 10.2147/copd.s312853] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 08/23/2021] [Indexed: 11/23/2022] Open
Abstract
PURPOSE To assess if early multiple-inhaler triple therapy (MITT) initiation in patients with chronic obstructive pulmonary disease (COPD) reduces subsequent healthcare resource utilization (HCRU), direct medical costs, and acute exacerbations of COPD (AECOPDs). PATIENTS AND METHODS This retrospective, longitudinal cohort study used electronic health records and linked hospital administrative data in England. COPD patients with an AECOPD between July 2012 and May 2016 (index), and who subsequently started MITT within 180 days were eligible. Patients with an AECOPD 6 months prior to index were excluded. HCRU, direct healthcare costs, and AECOPDs were assessed in the following 24-month period for early (≤30 days) and delayed (31-180 days) MITT initiators. RESULTS A total of 934 patients were included in the analysis and categorized as early (n=367, 39%) or delayed (n=567, 61%) MITT initiators. Mean patient age was 68.5 years and 53.2% were male. A significantly higher proportion of delayed MITT initiators required ≥1 outpatient appointment (all-cause) compared with early MITT initiators (87% vs 79%; p=0.0016). A significantly higher proportion of delayed MITT initiators required ≥1 COPD‑related inpatient stay versus early MITT initiators (47% vs 40%; p=0.0262). Over the 24-month follow-up, mean all-cause and COPD-related total healthcare costs were significantly higher in delayed MITT initiators compared with early MITT initiators (all‑cause: £11,348 vs £8126; p=0.0011; COPD-related: £7307 vs £4535; p=0.0009). CONCLUSION Delayed initiation of multiple-inhaler triple therapy was associated with higher all-cause and COPD-related costs, suggesting that earlier initiation of triple therapy in COPD patients may help reduce the economic burden on the healthcare system.
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Affiliation(s)
- Leah B Sansbury
- Epidemiology, Value Evidence and Outcomes, GlaxoSmithKline, Research Triangle Park, NC, USA
| | - Robert P Wood
- Observational Research, Adelphi Real World, Bollington, UK
| | | | - Yein Nam
- Observational Research, Adelphi Real World, Bollington, UK
| | - Afisi S Ismaila
- Value Evidence and Outcomes, GlaxoSmithKline, Collegeville, PA, USA
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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28
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Román-Rodríguez M, Kocks JWH. Targeting exertional breathlessness to improve physical activity: the role of primary care. NPJ Prim Care Respir Med 2021; 31:41. [PMID: 34504091 PMCID: PMC8429707 DOI: 10.1038/s41533-021-00254-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 08/19/2021] [Indexed: 02/08/2023] Open
Abstract
Primary care physicians (PCPs) play a crucial role in the diagnosis and management of chronic obstructive pulmonary disease (COPD). By working together with patients to target exertional breathlessness and increase physical activity, PCPs have an important role to play, early in the disease course, in improving patient outcomes in both the short and long term. In this article, we consider how physical activity affects disease progression from the PCP perspective. We discuss the role of pharmacological therapy, the importance of an holistic approach and the role of PCPs in assessing and promoting physical activity. The complexity and heterogeneity of COPD make it a challenging disease to treat. Patients' avoidance of activity, and subsequent decline in capacity to perform it, further impacts the management of the disease. Improving patient tolerance of physical activity, increasing participation in daily activities and helping patients to remain active are clear goals of COPD management. These may require an holistic approach to management, including pulmonary rehabilitation and psychological programmes in parallel with bronchodilation therapy, in order to address both physiological and behavioural factors. PCPs have an important role to optimise therapy, set goals and communicate the importance of maintaining physical activity to their patients. In addition, optimal treatment that addresses activity-related breathlessness can help prevent the downward spiral of inactivity and get patients moving again, to improve their overall health and long-term prognosis.
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Affiliation(s)
- Miguel Román-Rodríguez
- Son Pisà Primary Health Care Centre, Balearic Health System, Mallorca, Spain.
- Primary Care Chronic Respiratory Research Unit, Instituto de Investigación Sanitaria de las Islas Baleares (IdISBa), Mallorca, Spain.
| | - Janwillem W H Kocks
- General Practitioners Research Institute, Groningen, The Netherlands
- Groningen Research Institute for Asthma and COPD (GRIAC), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Observational and Pragmatic Research Institute, Singapore, Singapore
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29
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Pullen R, Miravitlles M, Sharma A, Singh D, Martinez F, Hurst JR, Alves L, Dransfield M, Chen R, Muro S, Winders T, Blango C, Muellerova H, Trudo F, Dorinsky P, Alacqua M, Morris T, Carter V, Couper A, Jones R, Kostikas K, Murray R, Price DB. CONQUEST Quality Standards: For the Collaboration on Quality Improvement Initiative for Achieving Excellence in Standards of COPD Care. Int J Chron Obstruct Pulmon Dis 2021; 16:2301-2322. [PMID: 34413639 PMCID: PMC8370848 DOI: 10.2147/copd.s313498] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 06/30/2021] [Indexed: 12/17/2022] Open
Abstract
Background Chronic obstructive pulmonary disease (COPD) are managed predominantly in primary care. However, key opportunities to optimize treatment are often not realized due to unrecognized disease and delayed implementation of appropriate interventions for both diagnosed and undiagnosed individuals. The COllaboratioN on QUality improvement initiative for achieving Excellence in STandards of COPD care (CONQUEST) is the first-of-its-kind, collaborative, interventional COPD registry. It comprises an integrated quality improvement program focusing on patients (diagnosed and undiagnosed) at a modifiable and higher risk of COPD exacerbations. The first step in CONQUEST was the development of quality standards (QS). The QS will be imbedded in routine primary and secondary care, and are designed to drive patient-centered, targeted, risk-based assessment and management optimization. Our aim is to provide an overview of the CONQUEST QS, including how they were developed, as well as the rationale for, and evidence to support, their inclusion in healthcare systems. Methods The QS were developed (between November 2019 and December 2020) by the CONQUEST Global Steering Committee, including 11 internationally recognized experts with a specialty and research focus in COPD. The process included an extensive literature review, generation of QS draft wording, three iterative rounds of review, and consensus. Results Four QS were developed: 1) identification of COPD target population, 2) assessment of disease and quantification of future risk, 3) non-pharmacological and pharmacological intervention, and 4) appropriate follow-up. Each QS is followed by a rationale statement and a summary of current guidelines and research evidence relating to the standard and its components. Conclusion The CONQUEST QS represent an important step in our aim to improve care for patients with COPD in primary and secondary care. They will help to transform the patient journey, by encouraging early intervention to identify, assess, optimally manage and followup COPD patients with modifiable high risk of future exacerbations.
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Affiliation(s)
- Rachel Pullen
- Observational and Pragmatic Research Institute, Singapore, Singapore
- Optimum Patient Care, Cambridge, UK
| | - Marc Miravitlles
- Pneumology Dept, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Anita Sharma
- Platinum Medical Centre, Chermside, QLD, Australia
| | - Dave Singh
- Division of Infection, Immunity & Respiratory Medicine, University of Manchester, Manchester University NHS Foundation Trust, Manchester, UK
| | - Fernando Martinez
- New York-Presbyterian Weill Cornell Medical Center, New York, NY, USA
| | - John R Hurst
- UCL Respiratory, University College London, London, UK
| | - Luis Alves
- EPI Unit, Institute of Public Health, University of Porto, Porto, Portugal
- Laboratory for Integrative and Translational Research in Population Health (ITR), Porto, Portugal
| | - Mark Dransfield
- Division of Pulmonary, Allergy, and Critical Care Medicine, Lung Health Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Rongchang Chen
- Key Laboratory of Respiratory Disease of Shenzhen, Shenzhen Institute of Respiratory Disease, Shenzhen People’s Hospital (Second Affiliated Hospital of Jinan University, First Affiliated Hospital of South University of Science and Technology of China), Shenzhen, People's Republic of China
| | - Shigeo Muro
- Department of Respiratory Medicine, Nara Medical University, Nara, Japan
| | - Tonya Winders
- USA & Global Allergy & Airways Patient Platform, Vienna, Austria
| | - Christopher Blango
- Janssen Pharmaceutical Companies of Johnson & Johnson, Philadelphia, PA, USA
| | | | | | | | | | | | - Victoria Carter
- Observational and Pragmatic Research Institute, Singapore, Singapore
- Optimum Patient Care, Cambridge, UK
| | - Amy Couper
- Observational and Pragmatic Research Institute, Singapore, Singapore
- Optimum Patient Care, Cambridge, UK
| | - Rupert Jones
- Research and Knowledge Exchange, Plymouth Marjon University, Plymouth, UK
| | - Konstantinos Kostikas
- Observational and Pragmatic Research Institute, Singapore, Singapore
- Respiratory Medicine Department, University of Ioannina School of Medicine, Ioannina, Greece
| | - Ruth Murray
- Observational and Pragmatic Research Institute, Singapore, Singapore
| | - David B Price
- Observational and Pragmatic Research Institute, Singapore, Singapore
- Optimum Patient Care, Cambridge, UK
- Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
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30
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D'Urzo AD, Singh D, Donohue JF, Chapman KR, Wise RA. Aclidinium bromide/formoterol fumarate as a treatment for COPD: an update. Expert Rev Respir Med 2021; 15:1093-1106. [PMID: 34137664 DOI: 10.1080/17476348.2021.1920403] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Introduction: Aclidinium/formoterol is a long-acting muscarinic antagonist (LAMA) and long-acting β2-agonist (LABA) dual bronchodilator used as a maintenance treatment for patients with chronic obstructive pulmonary disease (COPD). The efficacy of aclidinium/formoterol has been demonstrated consistently in patients with moderate-to-severe COPD versus placebo and monocomponents, with a comparable safety profile.Areas covered: This review examines recent research findings that expand our understanding of the impact of aclidinium/formoterol on the burden of COPD. Reviewed outcomes include improvements in lung function, respiratory symptoms, health-related quality of life, exercise tolerance, exacerbation rates, and clinically important deteriorations. In addition, the reported cardiovascular safety of aclidinium and current LAMA/LABA treatment recommendations are discussed.Expert opinion: Aclidinium/formoterol reduces disease burden in patients with COPD, including those that are treatment-naïve, without a significant increase in safety risk compared with monotherapies. Furthermore, evidence supports an improvement in lung function over a 24-hour period with aclidinium/formoterol treatment versus monotherapy and placebo, which may offer an advantage over some once-daily LAMA/LABA combinations. In summary, the recent evidence discussed in this review adds weight to the use of LAMA/LABA combinations as an initial therapy for certain patients newly diagnosed with COPD.
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Affiliation(s)
- Anthony D D'Urzo
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Dave Singh
- Medicines Evaluation Unit, Manchester University NHS Foundations Trust, University of Manchester, Manchester, UK
| | - James F Donohue
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina Pulmonary Critical Medicine, Chapel Hill, NC, USA
| | - Kenneth R Chapman
- Asthma and Airway Center, University Health Network, Toronto, ON, Canada
| | - Robert A Wise
- School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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31
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Bao H, Jia G, Cong S, Sun W, Fan J, Wang N, Feng Y, Wang B, Curtis JL, Wang L, Fang L, Chen Y. Phenotype and management of chronic obstructive pulmonary disease patients in general population in China: a nationally cross-sectional study. NPJ Prim Care Respir Med 2021; 31:32. [PMID: 34075048 PMCID: PMC8169915 DOI: 10.1038/s41533-021-00243-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 04/29/2021] [Indexed: 01/14/2023] Open
Abstract
This study aims to investigate the characteristics of the phenotype and management of chronic obstructive pulmonary disease (COPD) patients in the general population in China. We analyzed spirometry-confirmed COPD patients who were identified from a population-based, nationally representative sample in China. All participants were measured with airflow limitation severity based on post-bronchodilator FEV1 percent predicted, bronchodilator responsiveness, exacerbation history, and respiratory symptoms. Among a total of 9134 COPD patients, 90.3% were non-exacerbators, 2.9% were frequent exacerbators without chronic bronchitis, 2.0% were frequent exacerbators with chronic bronchitis, and 4.8% were asthma-COPD overlap. Less than 5% of non-exacerbators ever had pulmonary function testing performed. The utilization rate of inhaled medication in non-exacerbators, exacerbators without chronic bronchitis, exacerbators with chronic bronchitis, and asthma-COPD overlap was 1.4, 23.5, 29.5, and 19.4%, respectively. A comprehensive strategy for the management of COPD patients based on phenotype in primary care is urgently needed.
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Affiliation(s)
- Heling Bao
- National Center for Chronic and Non-communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, 27 Nanwei Road, Xicheng District, Beijing, China.,Department of Maternal and Child Health, School of Public Health, Peking University, 38 Xueyuan Road, Haidian District, Beijing, China
| | - Guohua Jia
- Department of Pulmonary and Critical Care Medicine, Peking University Third Hospital, 49 Huayuan North Road, Haidian District, Beijing, China
| | - Shu Cong
- National Center for Chronic and Non-communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, 27 Nanwei Road, Xicheng District, Beijing, China
| | - Wanlu Sun
- Department of Pulmonary and Critical Care Medicine, Peking University Third Hospital, 49 Huayuan North Road, Haidian District, Beijing, China
| | - Jing Fan
- National Center for Chronic and Non-communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, 27 Nanwei Road, Xicheng District, Beijing, China
| | - Ning Wang
- National Center for Chronic and Non-communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, 27 Nanwei Road, Xicheng District, Beijing, China
| | - Yajing Feng
- National Center for Chronic and Non-communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, 27 Nanwei Road, Xicheng District, Beijing, China
| | - Baohua Wang
- National Center for Chronic and Non-communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, 27 Nanwei Road, Xicheng District, Beijing, China
| | - Jeffrey L Curtis
- Department of Internal Medicine, University of Michigan Medical School, 150 W. Medical Center Drive, Ann Arbor, MI, USA.,Medicine Service, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, USA
| | - Linhong Wang
- National Center for Chronic and Non-communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, 27 Nanwei Road, Xicheng District, Beijing, China
| | - Liwen Fang
- National Center for Chronic and Non-communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, 27 Nanwei Road, Xicheng District, Beijing, China.
| | - Yahong Chen
- Department of Pulmonary and Critical Care Medicine, Peking University Third Hospital, 49 Huayuan North Road, Haidian District, Beijing, China.
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Spyratos D, Chloros D, Michalopoulou D, Tsiouprou I, Christoglou K, Sichletidis L. Underdiagnosis, false diagnosis and treatment of COPD in a selected population in Northern Greece. Eur J Gen Pract 2021; 27:97-102. [PMID: 34027790 PMCID: PMC8158270 DOI: 10.1080/13814788.2021.1912729] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND In the primary care setting, diagnosis and treatment of COPD is not always consistent with GOLD guidelines. OBJECTIVES To calculate the prevalence of COPD underdiagnosis, false diagnosis and treatment in the general population of northern Greece. METHODS Observational study in the context of an early COPD detection and smoking cessation project. Inclusion criteria: >40-year-old, current and former smokers (>10 pack-years) in five primary care centres of northern Greece from 2012 to 2019. Participation was achieved via a campaign (posters and advertisements in the mass media). RESULTS We examined 5,226 subjects (mean age: 58.2 ± 12.7 years, 61.5% males, current smokers: 56.2%) of whom 564 (10.8%) had symptoms and spirometrically confirmed COPD. There were 5 groups of 'interest:' a) 117/264 (44.3%) with a previous correct diagnosis COPD and correct treatment; b) 139/264 (52.7%) previous correct diagnosis COPD but overtreatment; c) 8/264 (3%) previous correct diagnosis COPD but undertreatment; d) 461 subjects (63.6% of those with previous COPD diagnosis) had previous false diagnosis of COPD (= also overtreatment); e) 300/564 (53.2%) previously not diagnosed COPD (=underdiagnosis and also undertreatment). We found that 322/461 (69.8%) of those with a previous false diagnosis have been prescribed long-acting bronchodilators plus ICS. CONCLUSION Among the general population subjects in northern Greece, more than 50% of patients with COPD were underdiagnosed, more than 50% of correctly diagnosed COPD patients were overtreated and most patients taking inhaled drugs were those with a false diagnosis of COPD (possibly GOLD stage 0).
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Affiliation(s)
- Dionisios Spyratos
- Pulmonary Department, Aristotle University of Thessaloniki, G. Papanikolaou Hospital, Thessaloniki, Greece
| | - Diamantis Chloros
- Pulmonary Department, Aristotle University of Thessaloniki, G. Papanikolaou Hospital, Thessaloniki, Greece
| | | | - Ioanna Tsiouprou
- Pulmonary Department, Aristotle University of Thessaloniki, G. Papanikolaou Hospital, Thessaloniki, Greece
| | | | - Lazaros Sichletidis
- Pulmonary Department, Aristotle University of Thessaloniki, G. Papanikolaou Hospital, Thessaloniki, Greece
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Effectiveness and Safety of COPD Maintenance Therapy with Tiotropium/Olodaterol versus LABA/ICS in a US Claims Database. Adv Ther 2021; 38:2249-2270. [PMID: 33721209 PMCID: PMC8107175 DOI: 10.1007/s12325-021-01646-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 02/02/2021] [Indexed: 11/18/2022]
Abstract
Introduction In patients with chronic obstructive pulmonary disease (COPD), treatment with long-acting muscarinic antagonist (LAMA)/long-acting β2-agonist (LABA) combination therapy significantly improves lung function versus LABA/inhaled corticosteroid (ICS). To investigate whether LAMA/LABA could provide better clinical outcomes than LABA/ICS, this non-interventional database study assessed the risk of COPD exacerbations, pneumonia, and escalation to triple therapy in patients with COPD initiating maintenance therapy with tiotropium/olodaterol versus any LABA/ICS combination. Methods Administrative healthcare claims and laboratory results data from the US HealthCore Integrated Research Databasesm were evaluated for patients with COPD initiating tiotropium/olodaterol versus LABA/ICS treatment (January 2013–March 2019). Patients were aged at least 40 years with a diagnosis of COPD (but not asthma) at cohort entry. A Cox proportional hazard regression model was used (as-treated analysis) to assess risk of COPD exacerbation, community-acquired pneumonia, and escalation to triple therapy, both individually and as a combined risk of any one of these events. Potential imbalance of confounding factors between cohorts was handled using fine stratification, reweighting, and trimming by exposure propensity score (high-dimensional); subgroup analyses were conducted on the basis of blood eosinophil levels and exacerbation history. Results The total population consisted of 61,985 patients (tiotropium/olodaterol n = 2684; LABA/ICS n = 59,301); after reweighting, the total was 42,953 patients (tiotropium/olodaterol n = 2600; LABA/ICS n = 40,353; mean age 65 years; female 54.5%). Patients treated with tiotropium/olodaterol versus LABA/ICS experienced a reduction in the risk of COPD exacerbations (adjusted hazard ratio 0.76 [95% confidence interval 0.68, 0.85]), pneumonia (0.74 [0.57, 0.97]), escalation to triple therapy (0.22 [0.19, 0.26]), and any one of these events (0.45 [0.41, 0.49]); the combined risk was similar irrespective of baseline eosinophils and exacerbation history. Conclusions In patients with COPD, tiotropium/olodaterol was associated with a lower risk of COPD exacerbations, pneumonia, and escalation to triple therapy versus LABA/ICS, both individually and in combination; the combined risk was reduced irrespective of baseline eosinophils or exacerbation history. Trial Registration ClinicalTrials.gov identifier, NCT04138758 (registered 23 October 2019). Graphic Abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1007/s12325-021-01646-5.
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Sha J, Worsnop CJ, Leaver BA, Vagias C, Kinsella P, Rahman MA, McDonald CF. Hospitalised exacerbations of chronic obstructive pulmonary disease: adherence to guideline recommendations in an Australian teaching hospital. Intern Med J 2021; 50:453-459. [PMID: 31157943 DOI: 10.1111/imj.14378] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 05/15/2019] [Accepted: 05/18/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Optimal management of exacerbations of chronic obstructive pulmonary disease (COPD) reduces patient morbidity and healthcare system burden. COPD guidelines, including the Global Initiative for Chronic Obstructive Lung Disease (GOLD) and the COPD-X Plan, provide evidence-based recommendations, but adherence in hospital practice is variable. AIMS To examine current practice in management of COPD exacerbations at an Australian teaching hospital and to compare with COPD-X Plan recommendations. METHODS Data were collected retrospectively from electronic medical records for admissions occurring during 1 May to 31 August 2016, and compared with recommendations from the COPD-X Plan. RESULTS A total of 134 patients (n = 68 females) was admitted for a COPD exacerbation during the study period. Mean age was 75.4 ± 10.2 years and 33.6% were current smokers. Airflow obstruction on spirometry was confirmed in 67.2% (mean forced expiratory volume in 1 s was 53 ± 22% predicted (1.2 ± 0.5 L)). Excellent adherence to the COPD-X Plan was demonstrated in the ordering of chest radiographs (97%) and electrocardiograms (94%). Supplemental oxygen was appropriately provided to all patients with oxygen saturation of <88%. All patients with confirmed hypercapnic respiratory failure were managed with non-invasive ventilation. Corticosteroids and bronchodilators were prescribed for the majority of patients. Areas of suboptimal practice included inadequate usage of arterial blood gases, excess supplemental oxygen in the absence of hypoxaemia, over-prescription of intravenous antimicrobials, low referral rates to pulmonary rehabilitation and insufficient smoking cessation counselling. CONCLUSIONS Level of adherence to guideline recommendations in the management of COPD exacerbations is inadequate and further strategies are required to elevate standards of practice.
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Affiliation(s)
- Joy Sha
- Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, Victoria, Australia.,Institute for Breathing and Sleep, Melbourne, Victoria, Australia
| | - Christopher J Worsnop
- Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, Victoria, Australia.,Institute for Breathing and Sleep, Melbourne, Victoria, Australia
| | - Benjamin A Leaver
- Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, Victoria, Australia
| | - Christopher Vagias
- Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, Victoria, Australia
| | - Paul Kinsella
- Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, Victoria, Australia
| | - Muhammad A Rahman
- La Trobe University/Austin Health Clinical School of Nursing and Midwifery, College of Science, Health and Engineering, Melbourne, Victoria, Australia
| | - Christine F McDonald
- Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, Victoria, Australia.,Institute for Breathing and Sleep, Melbourne, Victoria, Australia.,Department of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
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Bourbeau J, Bafadhel M, Barnes NC, Compton C, Di Boscio V, Lipson DA, Jones PW, Martin N, Weiss G, Halpin DMG. Benefit/Risk Profile of Single-Inhaler Triple Therapy in COPD. Int J Chron Obstruct Pulmon Dis 2021; 16:499-517. [PMID: 33688176 PMCID: PMC7935340 DOI: 10.2147/copd.s291967] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 02/07/2021] [Indexed: 12/12/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is associated with major healthcare and socioeconomic burdens. International consortia recommend a personalized approach to treatment and management that aims to reduce both symptom burden and the risk of exacerbations. Recent clinical trials have investigated single-inhaler triple therapy (SITT) with a long-acting muscarinic antagonist (LAMA), long-acting β2-agonist (LABA), and inhaled corticosteroid (ICS) for patients with symptomatic COPD. Here, we review evidence from randomized controlled trials showing the benefits of SITT and weigh these against the reported risk of pneumonia with ICS use. We highlight the challenges associated with cross-trial comparisons of benefit/risk, discuss blood eosinophils as a marker of ICS responsiveness, and summarize current treatment recommendations and the position of SITT in the management of COPD, including potential advantages in terms of improving patient adherence. Evidence from trials of SITT versus dual therapies in symptomatic patients with moderate to very severe airflow limitation and increased risk of exacerbations shows benefits in lung function and patient-reported outcomes. Moreover, the key benefits reported with SITT are significant reductions in exacerbations and hospitalizations, with data also suggesting reduced all-cause mortality. These benefits outweigh the ICS-class effect of higher incidence of study-reported pneumonia compared with LAMA/LABA. Important differences in trial design, baseline population characteristics, such as exacerbation history, and assessment of outcomes, have significant implications for interpreting data from cross-trial comparisons. Current understanding interprets the blood eosinophil count as a continuum that can help predict response to ICS and has utility alongside other clinical factors to aid treatment decision-making. We conclude that treatment decisions in COPD should be guided by an approach that considers benefit versus risk, with early optimization of treatment essential for maximizing long-term benefits and patient outcomes.
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Affiliation(s)
- Jean Bourbeau
- Respiratory Epidemiology and Clinical Research Unit, Department of Medicine, McGill University and Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Mona Bafadhel
- Nuffield Department of Medicine, University of Oxford, Oxford, Oxfordshire, UK
| | - Neil C Barnes
- Respiratory Therapy Area, GlaxoSmithKline, Brentford, Middlesex, UK
- William Harvey Institute, Bart’s and the London School of Medicine and Dentistry, London, UK
| | - Chris Compton
- Respiratory Therapy Area, GlaxoSmithKline, Brentford, Middlesex, UK
| | | | - David A Lipson
- Clinical Sciences, GlaxoSmithKline, Collegeville, PA, USA
- Pulmonary, Allergy and Critical Care Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Paul W Jones
- Respiratory Therapy Area, GlaxoSmithKline, Brentford, Middlesex, UK
- Institute of Infection and Immunity, St George’s, University of London, London, UK
| | - Neil Martin
- Respiratory Therapy Area, GlaxoSmithKline, Brentford, Middlesex, UK
- University of Leicester, Leicester, UK
| | - Gudrun Weiss
- Respiratory Therapy Area, GlaxoSmithKline, Brentford, Middlesex, UK
| | - David M G Halpin
- University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, UK
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Yawn BP, Mintz ML, Doherty DE. GOLD in Practice: Chronic Obstructive Pulmonary Disease Treatment and Management in the Primary Care Setting. Int J Chron Obstruct Pulmon Dis 2021; 16:289-299. [PMID: 33603355 PMCID: PMC7886101 DOI: 10.2147/copd.s222664] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 11/16/2020] [Indexed: 12/12/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality. Early detection and appropriate treatment and management of COPD can lower morbidity and perhaps mortality. Clinicians in the primary care setting provide the majority of COPD care and are pivotal in the diagnosis and management of COPD. In this review, we provide an overview of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2020 report, with a focus on the management of COPD in the primary care setting. We discuss the pathophysiology of COPD; describe COPD risk factors, signs, and symptoms that may facilitate earlier diagnosis of COPD; and reinforce the importance of spirometry use in establishing the diagnosis of COPD. Disease monitoring, as well as a review of the 2020 GOLD treatment recommendations, is also discussed. Patients and families are important partners in COPD management; therefore, we outline simple steps that may assist them in caring for those affected by COPD. Finally, we discuss nonpharmacological treatment options for COPD, COPD monitoring tools that may aid in the evaluation of disease progression and response to therapy, and the importance of developing a COPD action plan on an individualized basis.
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Affiliation(s)
- Barbara P Yawn
- Department of Family and Community Health, University of Minnesota, Minneapolis, MN, USA.,COPD Foundation, Miami, FL, USA
| | - Matthew L Mintz
- Department of Medicine, George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - Dennis E Doherty
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Kentucky, Lexington, KY, USA
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Turan PA, Turan O, Güldaval F, Anar C, Polat G, Büyükşirin M. Transitions between COPD groups: A cross-sectional study in Turkey. Respir Med 2021; 178:106310. [PMID: 33529994 DOI: 10.1016/j.rmed.2021.106310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 12/21/2020] [Accepted: 01/17/2021] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Since GOLD 2017 separates spirometry results from 'ABCD' groups, there have been some changes to the stages of COPD patients. Our aim was to investigate the shifts in COPD groups after GOLD 2017. METHODS COPD patients from outpatient clinics of 3 hospitals in Turkey were stratified into old and new ABCD groups according to exacerbation history, mMRC evaluation and spirometry results for both GOLD 2011 and 2017 assessments. Treatment protocols were also evaluated if they were suitable for both classifications. RESULTS There were 578 patients (334 men, 244 women) with a mean age of 65.21±10.42. The distribution of patients from group A to D was 28%, 15%, 15%, 42% (GOLD 2011) and 36%, 22%, 7% and 35% (GOLD 2017) respectively. There were shifts from group C to A (53.4%) and D to B (18.4%). The treatment suitability was 66.3% in GOLD 2011 and 60.9% in GOLD 2017. The most common inappropriate treatment protocol was triple therapy. Presence of exacerbations in last year, mMRC score, FEV1 level (p < 0.01 for three parameters) and proportion of males (p = 0.029) were statistically significantly higher in groups C and D of GOLD 2017 compared with new patients in group A and B of GOLD 2017 (shifted from GOLD 2011's C-D groups). CONCLUSION There were shifts from group C to A and D to B with GOLD 2017, which means some high-risk COPD patients were reclassified into low-risk groups. Despite guideline updates, there are still many COPD patients with overtreatment. To our knowledge, this is the first study examining transitions between COPD groups after GOLD 2017 in Turkey.
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Affiliation(s)
- P A Turan
- Department of Pulmonary Medicine. Menemen State Hospital, Izmir, Turkey(1).
| | - O Turan
- Department of Pulmonary Medicine, Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey(2)
| | - F Güldaval
- Department of Pulmonary Medicine, Dr. Suat Seren Chest Diseases and Surgery Training Hospital, Izmir, Turkey(3)
| | - C Anar
- Department of Pulmonary Medicine, Dr. Suat Seren Chest Diseases and Surgery Training Hospital, Izmir, Turkey(3)
| | - G Polat
- Department of Pulmonary Medicine, Dr. Suat Seren Chest Diseases and Surgery Training Hospital, Izmir, Turkey(3)
| | - M Büyükşirin
- Department of Pulmonary Medicine, Dr. Suat Seren Chest Diseases and Surgery Training Hospital, Izmir, Turkey(3)
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Abstract
Chronic obstructive pulmonary disease (COPD) has a profound impact on people living with the disease and has a high global economic and social burden. Often, people with COPD are undiagnosed, while those diagnosed are undertreated and undereducated on different aspects of COPD care. Although there are many published evidence-based treatment guidelines from different expert groups and societies, they are frequently not adhered to, which results in significant gaps in care. In particular, 'flare-ups' (known as exacerbations of COPD), which accelerate disease progression, are often under-reported, despite guidelines recommending an escalation of maintenance treatment to prevent subsequent flare-ups. Management of COPD should be proactive to prevent worsening of symptoms and to reduce the risk of future flare-ups and premature death, rather than a secondary reaction to a worsening health status. Key to this is patient access to accurate diagnosis, effective treatment and specialist care, which can vary widely due to socioeconomic differences, geographical locations and poor guideline implementation. In addition, the stigma associated with COPD can act as a barrier, which can result in people being reluctant to access treatment or clinicians being nihilistic. As global patient advocates, we have co-developed this patient charter to set a standard of care that people living with COPD should expect, raising awareness and understanding of the causes and consequences of COPD as well as the potential to improve patient care. Patients with COPD should be empowered to live the highest quality of life possible with the least number of flare-ups. We set out six principles in line with current COPD guideline recommendations, that should be implemented by governments, healthcare providers, policymakers, lung health industry partners and patients/caregivers to drive meaningful change in COPD care.
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Tongdee S, Sawunyavisuth B, Sukeepaisarnjaroen W, Boonsawat W, Khamsai S, Sawanyawisuth K. Clinical factors predictive of appropriate treatment in COPD: a community hospital setting. Drug Target Insights 2021; 15:21-25. [PMID: 34803374 PMCID: PMC8600449 DOI: 10.33393/dti.2021.2291] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 10/19/2021] [Indexed: 11/24/2022] Open
Abstract
Background: Chronic obstructive pulmonary disease (COPD) is a common respiratory disease. The appropriate treatment according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guideline was 19-60%. However, there are limited data on predictors of appropriate treatment in patients with COPD. This study aimed to evaluate risk factors of appropriate treatment in patients with COPD according to the GOLD guideline in a real-world community setting. Methods: This is a retrospective study conducted at a community hospital. Inclusion criteria were adult patients diagnosed as COPD treated at a COPD clinic. The primary outcome was the appropriate treatment, defined by correct pharmacological treatment by the GOLD guideline according to the ABCD severity assessment. Clinical predictors of appropriate treatment were executed by stepwise multivariate logistic regression analysis. Results: 136 patients with COPD met the study criteria. Of those, 100 patients had inappropriate treatment according to the GOLD guideline. Three factors were independently associated with the appropriate treatment including number of admissions, modified Medical Research Council (mMRC) score, and CAT score. These factors had adjusted odds ratio of 3.11, 2.86, and 1.26, respectively. Causes of inappropriate treatment were unavailability of long-acting muscarinic antagonist (LAMA) (51 patients; 79.69%), treated by inhaled corticosteroid (ICS) alone (12 patients; 18.75%), and treated with only bronchodilator (1 patient; 1.56%). Conclusions: Appropriate COPD patients’ treatment according to the GOLD guideline was 26.47% in community setting. Factors associated with severity of COPD were associated with prescribing appropriate treatments.
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Affiliation(s)
- Sukanya Tongdee
- Department of Medicine, Chumpae Hospital, Khon Kaen - Thailand
| | - Bundit Sawunyavisuth
- Department of Marketing, Faculty of Business Administration and Accountancy, Khon Kaen University, Khon Kaen - Thailand
| | | | - Watchara Boonsawat
- Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen - Thailand
| | - Sittichai Khamsai
- Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen - Thailand
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Marmy JL, Diedrich JP, Cadus C, Grendelmeier P, Tschacher A, Dieterle T, Chhajed PN, Leuppi JD. Adherence to GOLD Recommendations among Swiss Pulmonologists and General Practitioners. COPD 2020; 18:9-15. [PMID: 33342309 DOI: 10.1080/15412555.2020.1859469] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Significant variability in adherence to COPD management recommendations has been reported. We aimed to evaluate real-life COPD pharmacotherapy prescribing patterns and adherence to the 2017 Global Initiative for Chronic Obstructive Lung Disease (GOLD) global strategy in Switzerland. A questionnaire-based survey was conducted among Swiss general practitioners (GPs) and pulmonologists (PULs) from May 1 to November 30, 2017. Participants were invited to complete a questionnaire on their next 5-10 consecutive patients already receiving a pharmacological treatment for COPD. They were requested to assess dyspnea using the modified Medical Research Council (mMRC) dyspnea scale and to determine whether a treatment adjustment was indicated. Fifty-three PULs and 39 GPs completed questionnaires on 511 COPD patients. Dyspnea with mMRC grade ≥2 was reported in 62.5% of the patients, and 31.9% had had at least two exacerbations (or at least one with hospital admission) in the last 12 months. The vast majority (87.1%) of GOLD A patients were overtreated. In the GOLD B group, 52.2% of prescriptions were concordant with GOLD 2017 recommendations, but 37% of patients were overtreated. Among GOLD C patients, 49.2% received GOLD-adherent treatment and 47.5% were overtreated. In the GOLD D category, 78.8% of the patients received a treatment consistent with recommendations but 15.2% were undertreated. After reassessment of patient status, treatment was modified in 50.3% of the patients. This study confirms that discordance of real-world prescription patterns with international guidance is frequent. Further educational efforts are required to improve adherence to COPD management recommendations.
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Affiliation(s)
- Joana Louise Marmy
- University Clinic of Medicine, Cantonal Hospital Baselland, Liestal, Switzerland.,Faculty of Medicine, University of Basel, Basel, Switzerland
| | | | - Cordula Cadus
- University Clinic of Medicine, Cantonal Hospital Baselland, Liestal, Switzerland
| | - Peter Grendelmeier
- University Clinic of Medicine, Cantonal Hospital Baselland, Liestal, Switzerland.,Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Anne Tschacher
- University Clinic of Medicine, Cantonal Hospital Baselland, Liestal, Switzerland
| | - Thomas Dieterle
- University Clinic of Medicine, Cantonal Hospital Baselland, Liestal, Switzerland.,Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Prashant N Chhajed
- University Clinic of Medicine, Cantonal Hospital Baselland, Liestal, Switzerland.,Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Jörg Daniel Leuppi
- University Clinic of Medicine, Cantonal Hospital Baselland, Liestal, Switzerland.,Faculty of Medicine, University of Basel, Basel, Switzerland
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Quint JK, Venerus A, O’Leary C, Myland M, Holmgren U, Varghese P, Cabrera C. Prescribing Pathways to Triple Therapy: A Retrospective Observational Study of Adults with Chronic Obstructive Pulmonary Disease in the UK. Int J Chron Obstruct Pulmon Dis 2020; 15:3261-3271. [PMID: 33324049 PMCID: PMC7733404 DOI: 10.2147/copd.s278101] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 11/16/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose Treatment guidance for chronic obstructive pulmonary disease (COPD) recommends inhaled corticosteroid (ICS)+long-acting muscarinic antagonist+long-acting β2-agonist (LABA) triple therapy for patients who experience recurrent exacerbations, persistent breathlessness, or exercise limitation on dual therapy. However, information is limited on pathways to triple therapy in the UK. Patients and Methods A retrospective cohort study was conducted using de-identified patient-level data from UK primary care electronic medical records from January 1, 2005 to May 1, 2016. Data were included from patients who had their first triple therapy regimen (index date) recorded during the study period and a minimum of 12 months' pre-index data. Treatment pathways to triple therapy were recorded, and the proportion of patients on triple therapy before their COPD diagnosis was determined. Adherence to triple therapy was estimated using the proportion of days covered (PDC). Results After applying eligibility criteria, 82,300 patients were included, with a mean age at COPD diagnosis of 64.7 years. The major treatment pathway (27.9%) was the first initiation of ICS+LABA prior to triple therapy. Following COPD diagnosis, the median time to triple therapy was approximately 3.5 years. The estimated mean adherence to triple therapy was 81.8% PDC. Multivariate analysis showed that the following groups were more likely to have received previous therapy prior to triple therapy: females (versus males), patients with asthma (versus those without asthma), severe COPD (versus those with non-severe COPD), or fewer exacerbations (versus those with more exacerbations). Conclusion Treatment pathways to triple therapy in the UK are diverse, highlighting the need to better understand factors involved in clinical decision-making.
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Affiliation(s)
| | | | | | | | - Ulf Holmgren
- Real World Science and Digital, BioPharmaceuticals Medical, AstraZeneca, Gothenburg, Sweden
| | | | - Claudia Cabrera
- Real World Science and Digital, BioPharmaceuticals Medical, AstraZeneca, Gothenburg, Sweden
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
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Zeng Y, Cai S, Chen Y, Duan J, Zhao Y, Li X, Ma L, Liu Q, Zhu Y, Chen M, Zhou M, Chen P. Current Status of the Treatment of COPD in China: A Multicenter Prospective Observational Study. Int J Chron Obstruct Pulmon Dis 2020; 15:3227-3237. [PMID: 33324046 PMCID: PMC7732160 DOI: 10.2147/copd.s274024] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 11/16/2020] [Indexed: 12/30/2022] Open
Abstract
Background There is a large gap in the treatments for patients with COPD according to the Global Initiative for COPD (GOLD) recommendations. Determining the situation of therapies in the real world is necessary. This study aimed to characterize the real-world practical therapies of COPD and prognosis of patients after treatment for 1 year. Methods This study was a multicenter prospective observational study performed using a database set up by the Second Xiangya Hospital of Center South University. Detailed usage information for pharmacotherapies and nonpharmacotherapies for patients was collected, as well as the consistency of recommendations and patient adherence. Moreover, the effect of therapies after 1 year was calculated by comparing lung function and symptoms. Results Ultimately, 4,796 patients with COPD from 12 hospitals in China were eligible. LAMA (39.1%), LAMA + LABA/ICS (39.0%) and LABA/ICS (14.4%) were the top three inhalants. We found that 42.7% of Group A patients, 61.6% of Group B patients and 30% of Group C patients were following inappropriate therapy, especially overuse of ICS. Only 3.9% (95% CI 2.4, 5.4) of patients used oxygen therapy, and 1.8% (95% CI 1.5, 2.3) used noninvasive positive pressure ventilation at home. Among these patients, 33.2% had poor adherence. A total of 452 patients completed 1 year of follow-up. After 1 year of treatment, the lung function of FEV1/FVC decreased (P=0.001) and the mMRC score increased (P<0.001). There was no change in CAT scores (P>0.05). Conclusion This study highlights a significant discrepancy between recommendations for managing patients with COPD in GOLD report, and in real-world clinical practice in China. Over-prescription of ICS and under-prescription of nonpharmacologic therapy were common. The adherence to treatment of patients was poor, and the real-life treatment effectiveness was unsatisfactory. More attention should be paid to the implementation of recommendations and standardized administration of therapies.
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Affiliation(s)
- Yuqin Zeng
- Department of Pulmonary and Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China.,Research Unit of Respiratory Disease, Central South University, Changsha, Hunan, People's Republic of China.,Hunan Centre for Evidence-Based Medicine, Changsha, Hunan, People's Republic of China
| | - Shan Cai
- Department of Pulmonary and Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China.,Research Unit of Respiratory Disease, Central South University, Changsha, Hunan, People's Republic of China.,Hunan Centre for Evidence-Based Medicine, Changsha, Hunan, People's Republic of China
| | - Yan Chen
- Department of Pulmonary and Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China.,Research Unit of Respiratory Disease, Central South University, Changsha, Hunan, People's Republic of China.,Hunan Centre for Evidence-Based Medicine, Changsha, Hunan, People's Republic of China
| | - Jiaxi Duan
- Department of Pulmonary and Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China.,Research Unit of Respiratory Disease, Central South University, Changsha, Hunan, People's Republic of China.,Hunan Centre for Evidence-Based Medicine, Changsha, Hunan, People's Republic of China
| | - Yiyang Zhao
- Department of Pulmonary and Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China.,Research Unit of Respiratory Disease, Central South University, Changsha, Hunan, People's Republic of China.,Hunan Centre for Evidence-Based Medicine, Changsha, Hunan, People's Republic of China
| | - Xin Li
- Division 4 of Occupational Disease, Hunan Occupational Disease Prevention and Treatment Hospital, Changsha, Hunan, People's Republic of China
| | - Libing Ma
- Department of Respiratory and Critical Care Medicine, Affiliated Hospital of Guilin Medical University, Guilin, Guangxi, People's Republic of China
| | - Qimi Liu
- Department of Respiratory and Critical Care Medicine, The Second People's Hospital of Guilin, Guilin, Guangxi, People's Republic of China
| | - Yingqun Zhu
- Department of Respiratory and Critical Care Medicine, The Third Hospital of Changsha, Changsha, Hunan, People's Republic of China
| | - Ming Chen
- Department of Respiratory and Critical Care Medicine, No.1 Traditional Chinese Medicine Hospital of Changde City, Changde, Hunan, People's Republic of China
| | - Meiling Zhou
- Department of Respiratory and Critical Care Medicine, The First People's Hospital of Huaihua City, Huaihua, Hunan, People's Republic of China
| | - Ping Chen
- Department of Pulmonary and Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China.,Research Unit of Respiratory Disease, Central South University, Changsha, Hunan, People's Republic of China.,Hunan Centre for Evidence-Based Medicine, Changsha, Hunan, People's Republic of China
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43
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Ming SWY, Haughney J, Ryan D, Small I, Lavorini F, Papi A, Singh D, Halpin DMG, Hurst JR, Patel S, Ochel M, Kocks J, Carter V, Hardjojo A, Price DB. A Comparison of the Real-Life Clinical Effectiveness of the Leading Licensed ICS/LABA Combination Inhalers in the Treatment for COPD. Int J Chron Obstruct Pulmon Dis 2020; 15:3093-3103. [PMID: 33273812 PMCID: PMC7705280 DOI: 10.2147/copd.s263745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 10/26/2020] [Indexed: 11/23/2022] Open
Abstract
Introduction The Fostair® 100/6 (BDP/FF) pressurized metered-dose inhaler, delivering an extrafine formulation, is licensed for asthma and COPD in the UK. However, its real-life effectiveness for COPD has not been evaluated. This study compared the clinical effectiveness of BDP/FF against other licensed ICS/LABA combination inhalers: the Seretide® Accuhaler® (FP/SAL) and the Symbicort® Turbohaler® (BUD/FF). Methods A matched historical cohort study was conducted using records of patients with diagnostic codes for COPD from the Optimum Patient Care Research Database (OPCRD). Patients who had received BDP/FF as their first ICS/LABA were matched 1:1 with patients who had received FP/SAL or BUD/FF, resulting in two matched comparisons. Additional analysis was conducted on patients who had never had diagnostic codes for asthma. Noninferiority in terms of the proportion of patients with moderate/severe COPD exacerbations on the different inhalers in the following year was assessed. Noninferiority was achieved if the upper CI limit were ≤1.2. Results This study included 537 and 540 patient pairs in the BDP/FF vs FP/SAL cohort and the BDP/FF vs BUD/FF cohort, respectively. The proportion of patients with COPD exacerbations in the BDP/FF group was not significantly different from either the FP/SAL (68.7% vs 70.2%, AOR 0.89, 95% CI 0.67–1.19) or BUD/FF group (68.5% vs 69.4%, AOR 0.79, 95% CI 0.58–1.08). Noninferiority of BDP/FF in preventing COPD exacerbations was fulfilled in both comparisons. In patients without asthma, BDP/FF was also noninferior to BUD/FF (proportion with COPD exacerbations, 67.8% vs 64.7%, AOR 0.79, 95% CI 0.51–1.1997). Additionally, a significantly lower proportion of patients prescribed BDP/FF had COPD exacerbations than FP/SAL (64.8% vs 73.7%, AOR 0.64 95% CI 0.43–0.96). Conclusion Initiating ICS/LABA treatment of COPD with extrafine-formulation BDP/FF was noninferior in preventing moderate/severe exacerbations compared to FP/SAL and BUD/FF.
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Affiliation(s)
| | - John Haughney
- Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | | | | | - Federico Lavorini
- Department of Experimental and Clinical Medicine, Careggi University Hospital, Florence, Italy
| | | | - Dave Singh
- University of Manchester, Manchester University NHS Foundation Trust, Manchester, UK
| | | | - John R Hurst
- UCL Respiratory, University College London, London, UK
| | | | | | - Janwillem Kocks
- Observational and Pragmatic Research Institute, Singapore, Singapore.,General Practitioners Research Institute, Groningen, the Netherlands.,University of Groningen, University Medical Center Groningen, GRIAC Research Institute, Groningen, the Netherlands
| | - Victoria Carter
- Observational and Pragmatic Research Institute, Singapore, Singapore
| | - Antony Hardjojo
- Observational and Pragmatic Research Institute, Singapore, Singapore
| | - David B Price
- Observational and Pragmatic Research Institute, Singapore, Singapore.,Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
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O'Halloran L, Purcell A, Ryan E, O'Doherty J, Troddyn L, Slepanek M, O'Driscoll N, O'Reilly O, Stassen P, Bennett SA, O'Connor R. A snapshot of chronic obstructive pulmonary disease management in general practice in Ireland. Ir J Med Sci 2020; 190:1055-1061. [PMID: 33216315 DOI: 10.1007/s11845-020-02435-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 11/11/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is a leading cause of death and disability. Its diagnosis, classification and management are complex. There is a paucity of data on the standard of COPD management in Irish general practice. AIMS We studied whether COPD diagnosis and management was in accordance with the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines. We investigated if patients who were smokers had received smoking cessation advice. We examined whether influenza and pneumococcal vaccination had been given. METHODS Ten general practices affiliated with the Irish Mid-West Specialist Training Programme in General Practice (GP) were searched, to determine which patients had a diagnosis of COPD. A data-collection audit tool was developed using GOLD 2019 guidelines. Results were tabulated in SPSS. Descriptive statistics were used. RESULTS Of 482 patients studied, 91.7% were eligible for free GP care. In 49.4%, the diagnosis of COPD had been made appropriately. In 56.2%, there was no evidence that the stage of COPD had been formally assessed. Of the patients studied, 33.2% were deemed to be receiving appropriate therapy. Smoking status was documented in 99.6% of cases studied and 59.9% were ex-smokers, while 25.9% were current smokers. Appropriate smoking cessation advice had been offered to 71% of eligible patients. Influenza vaccine had been given to 66.2% in the previous 12 months. A total of 53.9% had ever received pneumococcal vaccination. CONCLUSIONS This study provides a comprehensive snapshot of care in Irish general practice for patients with COPD prior to introduction of the Chronic Disease Management programme (CDM).
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Affiliation(s)
- Liam O'Halloran
- Mid-West Specialist Training Programme in General Practice, University of Limerick, Plassey, Limerick, Ireland.
| | - Amy Purcell
- Mid-West Specialist Training Programme in General Practice, University of Limerick, Plassey, Limerick, Ireland
| | - Eoin Ryan
- Mid-West Specialist Training Programme in General Practice, University of Limerick, Plassey, Limerick, Ireland
| | - Jane O'Doherty
- Department of General Practice, School of Medicine, University of Limerick, Plassey, Limerick, Ireland
| | - Louise Troddyn
- Mid-West Specialist Training Programme in General Practice, University of Limerick, Plassey, Limerick, Ireland
| | - Martin Slepanek
- Mid-West Specialist Training Programme in General Practice, University of Limerick, Plassey, Limerick, Ireland
| | - Neil O'Driscoll
- Mid-West Specialist Training Programme in General Practice, University of Limerick, Plassey, Limerick, Ireland
| | - Orlaith O'Reilly
- Mid-West Specialist Training Programme in General Practice, University of Limerick, Plassey, Limerick, Ireland
| | - Paul Stassen
- Mid-West Specialist Training Programme in General Practice, University of Limerick, Plassey, Limerick, Ireland
| | - Sarah Anne Bennett
- Mid-West Specialist Training Programme in General Practice, University of Limerick, Plassey, Limerick, Ireland
| | - Raymond O'Connor
- Mid-West Specialist Training Programme in General Practice, University of Limerick, Plassey, Limerick, Ireland
- Department of General Practice, School of Medicine, University of Limerick, Plassey, Limerick, Ireland
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Farne H. Review of the American Thoracic Society guidelines on the pharmacological management of patients with chronic obstructive pulmonary disease. Br J Hosp Med (Lond) 2020; 81:1-4. [PMID: 33263472 DOI: 10.12968/hmed.2020.0460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This article summarises the recommendations of the new American Thoracic Society guidelines on the pharmacological management of chronic obstructive pulmonary disease, comments on how they differ from other guidelines, and considers the research needs and unanswered questions posed.
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Affiliation(s)
- Hugo Farne
- National Heart and Lung Institute, Imperial College, London, UK
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46
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Moretz C, Hahn B, White J, Goolsby Hunter A, Essoi B, Elliott C, Ray R. Symptom Burden and GOLD Classification in Medicare Advantage Patients with COPD Initiating Umeclidinium/Vilanterol or Fluticasone Propionate/Salmeterol Therapy. Int J Chron Obstruct Pulmon Dis 2020; 15:2715-2725. [PMID: 33149569 PMCID: PMC7605915 DOI: 10.2147/copd.s265037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 09/23/2020] [Indexed: 12/02/2022] Open
Abstract
Background Long-acting muscarinic antagonist/long-acting β2-agonist (LAMA/LABA) provide greater improvements in lung function and symptoms than inhaled corticosteroid (ICS)/LABA in patients with chronic obstructive pulmonary disease (COPD). This study evaluated symptom burden and Global Initiative for Obstructive Lung Disease (GOLD) categorization among patients who recently initiated umeclidinium/vilanterol (UMEC/VI; LAMA/LABA) or fluticasone propionate/salmeterol (FP/SAL; ICS/LABA) single-inhaler dual therapy. Methods COPD-diagnosed Medicare Advantage enrollees aged ≥65 years were identified from the Optum Research Database (ORD). Eligible patients had ≥1 pharmacy claim for UMEC/VI or FP/SAL in the 6-month period before sample identification, with no evidence of triple therapy (ICS/LAMA/LABA), asthma, or lung cancer. Symptom burden was assessed via cross-sectional surveys using the COPD Assessment Test (CAT) and modified Medical Research Council (mMRC) dyspnea scale. Patients were classified into GOLD categories using patient-reported symptoms and claims-based exacerbation history. Treatment groups were balanced on potential confounders using inverse probability of treatment weighting (IPTW). CAT and mMRC scores were analyzed with generalized linear regression models using IPTW propensity scores. Results The final analytic sample included 789 respondents (UMEC/VI: N=392; FP/SAL: N=397). Approximately 66% patients were classified as GOLD B when assessing symptoms with CAT and mMRC together, or CAT alone; more patients were classified as GOLD A (~40%) than GOLD B (~36%) using mMRC alone. Proportions of patients in each GOLD group were similar between treatment cohorts. Post-IPTW multivariable modeling showed similar symptom burden between treatment groups. Conclusion After controlling for baseline characteristics, symptom burden was similar between patients receiving UMEC/VI or FP/SAL. GOLD classification using mMRC produced more conservative results compared with CAT, potentially underestimating patient symptoms. Many patients receiving FP/SAL were classified as GOLD A or B, despite GOLD recommending non-ICS-containing therapy in these patients. These findings support the need for routine assessment of symptoms in patients with COPD.
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Affiliation(s)
- Chad Moretz
- US Value Evidence & Outcomes, GlaxoSmithKline, Research Triangle Park, NC, USA
| | - Beth Hahn
- US Value Evidence & Outcomes, GlaxoSmithKline, Research Triangle Park, NC, USA
| | | | | | | | | | - Riju Ray
- US Medical Affairs, GlaxoSmithKline, Research Triangle Park, NC
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47
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Haroon S, Adab P, Dickens AP, Sitch AJ, Rai K, Enocson A, Fitzmaurice DA, Jordan RE. Impact of COPD case finding on clinical care: a prospective analysis of the TargetCOPD trial. BMJ Open 2020; 10:e038286. [PMID: 33020099 PMCID: PMC7537458 DOI: 10.1136/bmjopen-2020-038286] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES To investigate the impact of chronic obstructive pulmonary disease (COPD) case finding on clinical care. DESIGN We conducted a prospective observational analysis of data from a pragmatic cluster randomised controlled trial in primary care in the West Midlands, UK (TargetCOPD). This compared alternative methods of COPD case finding against usual care. Data were extracted from electronic healthcare records and self-reported questionnaires for a subset of patients with newly diagnosed COPD. SETTING 50 general practices that participated in the TargetCOPD trial. PARTICIPANTS Patients aged 40-79 years newly identified with COPD by targeted case finding or by usual care, from 10 August 2012 to 22 June 2014. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was addition to a COPD register by the end of the trial. The secondary outcome was a clinical care score, derived from the sum of clinical assessments and relevant interventions. Associations between participant characteristics and the primary and secondary outcomes were assessed using multilevel regression. RESULTS 857 patients identified with COPD by case finding and 764 by usual care were included. Only 21.2% of case-found patients had been added to a COPD register, compared with 92.7% of those diagnosed by usual care. The odds of being added were greater in smokers (adjusted OR 8.68, 95% CI 2.53 to 29.8), and in those with lower percentage of predicted forced expiratory volume in 1 s (adjusted OR 0.96 per percentage rise, 95% CI 0.95 to 0.98). Patients who had been added to a COPD register had a significantly higher clinical care score (mean difference 5.06, 95% CI 4.36 to 5.75). CONCLUSIONS Only one in five case-found patients had been registered with COPD. Patients added to a COPD register received significantly higher levels of appropriate clinical care. TRIAL REGISTRATION NUMBER ISRCTN14930255; Post-results.
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Affiliation(s)
- Shamil Haroon
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Peymane Adab
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Andrew P Dickens
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Alice J Sitch
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Kiran Rai
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Alexandra Enocson
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - David A Fitzmaurice
- Warwick Medical School - Health Sciences, University of Warwick, Coventry, UK
| | - Rachel E Jordan
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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Monteagudo M, Nuñez A, Solntseva I, Dhalwani N, Booth A, Barrecheguren M, Lambrelli D, Miravitlles M. Treatment Pathways Before and After Triple Therapy in COPD: A Population-based Study in Primary Care in Spain. Arch Bronconeumol 2020; 57:205-213. [PMID: 33004238 DOI: 10.1016/j.arbres.2020.07.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 07/06/2020] [Accepted: 07/14/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Recent data from real world clinical practices on the use of Triple Therapy (TT) in patients with COPD are scarce. METHODS Observational population-based study with longitudinal follow-up in patients with COPD identified in a primary care electronic medical records database in Catalonia, covering 80% of the general population. The aims were to characterize COPD patients who initiated TT and to describe treatment pathways before and after TT initiation. Time to and probability of step down or complete discontinuation of TT was described using restricted mean survival time and Kaplan-Meier analysis. RESULTS A total of 34,018 COPD patients initiated TT during the study period. Of them, 23,867 (70.1%) were GOLD A/B. 18,453 (54.2%) were non-exacerbators, 9931 (29.2%) infrequent exacerbators, 5634 (16.5%) frequent exacerbators and 1923 (5.6%) had asthma-COPD overlap. Drugs most frequently used prior to initiation of TT were long-acting antimuscarinics (22.5%) and combination of long-acting beta2 agonists/inhaled corticosteroids (15.2%). A total of 11,666 (34.3%) stepped down and 1091 (3.2%) discontinued TT during follow-up. Step down following TT was more likely in patients with severe COPD, especially during the first year; however, discontinuation was more common among patients with mild COPD. CONCLUSION Most patients initiating treatment with TT were non exacerbators and continued on the same treatment over time regardless severity of disease. Stepping down was more frequent in severe patients, while discontinuation was more common among mild patients. Overall, it appears that TT is extensively used in primary care for treatment of patients with COPD.
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Affiliation(s)
- Mònica Monteagudo
- Primary Care University Research Institute Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain; Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Barcelona, Spain
| | - Alexa Nuñez
- Pneumology Department, Hospital Universitari Vall d́Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus. CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain; Medicine Department, Autonomous University of Barcelona (UAB), Bellaterra (Cerdanyola del Vallés), Barcelona, Spain
| | - Iryna Solntseva
- Primary Care University Research Institute Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
| | | | - Alison Booth
- Medicine Department, Autonomous University of Barcelona (UAB), Bellaterra (Cerdanyola del Vallés), Barcelona, Spain; Evidera, London, UK
| | - Miriam Barrecheguren
- Pneumology Department, Hospital Universitari Vall d́Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus. CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | | | - Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d́Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus. CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain; Medicine Department, Autonomous University of Barcelona (UAB), Bellaterra (Cerdanyola del Vallés), Barcelona, Spain.
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49
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Savran O, Godtfredsen N, Sørensen T, Jensen C, Ulrik CS. COPD patients prescribed inhaled corticosteroid in general practice: Based on disease characteristics according to guidelines? Chron Respir Dis 2020; 16:1479973119867949. [PMID: 31431060 PMCID: PMC6704538 DOI: 10.1177/1479973119867949] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
In a primary care setting, our aim was to investigate characteristics of patients classified as having chronic obstructive pulmonary disease (COPD) and currently being prescribed inhaled corticosteroids (ICSs). The electronic patient record system in each participating general practice was searched for patients coded as COPD (ICPC, Second Edition code R95) and treated with ICS (ACT code R03AK and R03BA, that is, ICS in combination with a long-acting β2-agonist) or ICS as monotherapy. Data, if available, on demographics, smoking habits, spirometry, COPD medication, symptom score, blood eosinophils, co-morbidity and exacerbation history were retrieved from the medical records for all identified cases. Of all patients registered in the 138 participating general practices, 12.560 (3%) were coded as COPD, of whom 32% were prescribed ICS. The final study sample comprised 2.289 COPD patients currently prescribed ICS (98% also prescribed long-acting β2-agonist), with 24% being coded as both COPD and asthma. Post-bronchodilator spirometry was available in 79% (mean forced expiratory volume in 1 second 60% pred (standard deviation (SD) 23.3)), symptom severity score in 53% (mean Medical Research Council score 2.7 (SD 1.1)) and 56% of the COPD patients had had no exacerbation in the previous year (and 45% not within the 2 previous years). Blood eosinophils were measured in 67% of the patients. Information on severity of airflow limitation was missing in 15% of the patients, and the combined information on symptom severity and exacerbation history was missing in in 46%. Most of the patients (74%) were managed only by their general practitioner. Although only one-third of the COPD patients were prescribed ICSs, our findings from this study of a large cohort of patients prescribed ICSs for COPD in general practice suggest that more detailed assessment of diagnosis and disease characteristics is likely to improve the risk–benefit ratio of maintenance therapy with ICSs in COPD patients managed in primary care.
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Affiliation(s)
- Osman Savran
- 1 Respiratory Research Unit Hvidovre, Department of Respiratory Medicine, Hvidovre Hospital, Hvidovre, Denmark
| | - Nina Godtfredsen
- 1 Respiratory Research Unit Hvidovre, Department of Respiratory Medicine, Hvidovre Hospital, Hvidovre, Denmark.,2 Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | | | - Charlotte Suppli Ulrik
- 1 Respiratory Research Unit Hvidovre, Department of Respiratory Medicine, Hvidovre Hospital, Hvidovre, Denmark.,2 Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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50
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Pulmonologists Adherence to the Chronic Obstructive Pulmonary Disease GOLD Guidelines: A Goal to Improve. ACTA ACUST UNITED AC 2020; 56:medicina56090422. [PMID: 32825456 PMCID: PMC7558424 DOI: 10.3390/medicina56090422] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 08/05/2020] [Accepted: 08/19/2020] [Indexed: 01/09/2023]
Abstract
Background and objectives: Data about pulmonologist adherence to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines showed a great variability and cannot be extrapolated. The present study investigates the current pharmacological prescribing practices in the treatment of chronic obstructive pulmonary disease (COPD) according to the 2017 GOLD guidelines, to determine the level of pulmonologist adherence and to identify possible factors that influence physician adherence. Materials and methods: This retrospective study took place between 1 February and 30 April 2018 in Pneumophtysiology Clinical Hospital Cluj-Napoca. We included 348 stable COPD outpatients classified according to the 2017 GOLD strategy in the ABCD risk groups. Pulmonologist adherence was defined as appropriate if the recommended pharmacological therapy was the first- or alternative-choice drug according to the guidelines, and inappropriate (overtreatment, undertreatment) if it was not in line with these recommendations. Results: The most prescribed treatment was the combination long-acting beta agonist (LABA) + long-acting antimuscarinic agent (LAMA) (34.77%), followed by LAMA + LABA + inhaled corticosteroid (ICS). Overall, pneumologist adherence was 79.02%. The most inappropriate therapies were in Group B (33.57%), followed by 33.33% in Group A. Compared to Groups C and D (analyzed together), Groups A and B had a 4.65 times higher chance (p = 0.0000001) of receiving an inappropriate therapy. Patients with cardiovascular comorbidities had a 1.89 times higher risk of receiving an inappropriate therapy (p = 0.021). ICS overprescription was the most common type of inappropriateness (17.81%). Groups C and D had a 3.12 times higher chance of being prescribed ICS compared to Groups A and B (p = 0.0000004). Conclusions: Pulmonologist adherence to the GOLD guidelines is not optimal and needs to be improved. Among the factors that influence the inappropriateness of COPD treatments, cardiovascular comorbidities and low-risk Groups A and B are important. ICS represent the most prescribed overtreatment. Further multicentric studies are needed to evaluate all factors that might influence the adherence rate.
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