An evaluation of early medication use for COPD: a population-based cohort study

Abstract

PurposeThe aim of this study was to evaluate the first initiation, sequence of addition, and appropriate prescribing of COPD medications in Manitoba, Canada.Patients and methodsA population-based cohort study of COPD medication use was conducted using administrative health care data (1997–2012). Those aged ≥35 years with COPD based on three or more COPD-related outpatient visits over a rolling 24-month window or at least one COPD-related hospitalization were included. The first medication(s) dispensed on or after the date of COPD diagnosis were determined based on pharmacy claims. The next medication(s) in sequence were determined to be additions or switches to the previous regimen. Evaluation of guideline-based appropriateness to receive inhaled corticosteroids (ICS) was based on exacerbation history and past medication use.ResultsOf 13,369 patients dispensed COPD medications after diagnosis, 66.0% were dispensed short-acting bronchodilators as first medications. Although long-acting bronchodilators alone were uncommonly used as first or subsequent medications, ICS were dispensed as first medications in 28.2% of patients. Over the study period, use of short-acting bronchodilators as first medications declined from 70.6% to 59.4% (P<0.0001), whereas the use of ICS as a first medication increased from 23.5% to 34.4% (P<0.0001). Dispensation of an ICS plus a long-acting β-agonist increased dramatically from 1.2% to 27.3% (P<0.0001). By the end of the study period, the majority of patients (53.3%) were being initiated on two or more medications. Of 5,823 patients dispensed an ICS, 52.4% met Canadian guideline criteria for initiating an ICS, whereas 0.3% met Global Initiative for Chronic Obstructive Lung Disease guideline criteria.ConclusionThe use of first-line medications has declined over time, replaced primarily by combination inhalers prescribed early without prior trials of appropriate next step medications. This, along with an increasingly predominant use of multiple first medications, indicates a significant degree of medication burden in this already complex patient population.

<p>Trends in prescriptions and costs of inhaled medications in chronic obstructive pulmonary disease: a 19-year population-based study from Canada</p>

“…Our findings are also generally similar to a study by Falk et al, based on administrative health data from another Canadian province Manitoba 26. They assessed prescription patterns in the period from 1997 to 2012, and found that the use of SABA or SAMA as first-line medications declined from 70.6% of the patients to 59.4%, whereas the use of ICS increased from 23.5% to 34.4%.…”

Hospitalised exacerbations of chronic obstructive pulmonary disease: adherence to guideline recommendations in an Australian teaching hospital

“…This has been shown previously, where an Australian study found that 52.4% of 707 patients with COPD from a tertiary hospital were prescribed an ICS despite having FEV 1 of ≥50% predicted . A Canadian paper described only 0.3% of their cohort met criteria as determined by GOLD for initiating an ICS, while studies from the United Kingdom have also reported a similar trend in practice …”

Overuse and Misuse of Inhaled Corticosteroids Among Veterans with COPD: a Cross-sectional Study Evaluating Targets for De-implementation

“…Collectively, the degree of potentially inappropriate ICS prescriptions is consistent with the overall literature that demonstrates relatively poor quality of care for patients with COPD. 16,18,29,30 Additionally, we identified particular patient characteristics associated with overuse and misuse that could be used to focus efforts to prevent low-value prescribing. Our findings indicate that there are patient characteristics associated with an increased likelihood of inappropriate ICS use, regardless of GOLD statement used to determine appropriateness of ICS, many of which are also associated with receipt of other forms of low-value care.…”

“…12,[15][16][17] Bringing care into alignment with current evidence and the most recent GOLD recommendations represents an opportunity to improve safety of care through de-implementation of a low-value practice, as the risk of pneumonia falls quickly after discontinuation of ICS. 12,15,18 To develop effective and efficient de-implementation strategies, health systems need to understand the magnitude of potentially inappropriate ICS use as well as identify individual and health system factors that might contribute to the problem.…”