Adherence to Long-Acting Bronchodilators After Discharge for COPD: How Much of the Geographic Variation is Attributable to the Hospital of Discharge and How Much to the Primary Care Providers?

Figures & data

Figure 1. The cross-classified structure.

Figure 2. The exclusion criteria flowchart.

Table 1. Prevalence of proxies of COPD severity, concomitant respiratory diseases and previous use of drugs, by age group.

Age group (years)	45–54	55–64	65–74	75–84	85+	Total
N.	578	1,670	4,032	5,222	1,676	13,178
Proxy of COPD severity
Previous admissions for COPD (%)	2.1	2.7	3.8	3.3	1.6	3.1
Respiratory failure (%)	36.0	43.8	48.1	46.8	42.2	45.8
Invasive respiratory procedures (%)	2.4	1.9	1.7	1.7	0.8	1.6
Staying in intensive care unit (%)	1.7	2.3	2.2	2.1	1.6	2.1
Emergency visits for COPD (%)	4.2	4.5	4.6	4.8	3.5	4.5
Concomitant respiratory diseases
Asthma (%)	9.7	5.9	3.1	2.6	1.8	3.4
Chronic respiratory diseases other than COPD (%)	5.7	5.6	5.8	5.8	3.6	5.5
Pulmonary infections (%)	12.6	12.6	15.1	15.7	15.9	15.0
Acute pulmonary symptoms (%)	8.0	8.4	8.5	8.5	8.7	8.5
Sleep apnoea syndrome (%)	5.4	5.0	3.3	1.5	0.4	2.5
Previous use of drugs
Long-acting bronchodilators (%)	37.5	48.2	54.1	52.1	36.1	49.6
Oral corticosteroids (%)	34.9	36.4	40.4	38.3	32.7	37.8
Antibacterials (%)	73.9	75.7	79.6	81.3	78.1	79.3
Cardiovascular drugs (%)	51.6	67.8	83.3	89.9	93.7	83.9

Table 2. Prevalence of co-morbidities, by age group.

Age group (years)	45–54	55–64	65–74	75–84	85+	Total
N.	578	1,670	4,032	5,222	1,676	13,178
Diabetes (%)	16.4	19.5	23.9	22.1	18.6	21.6
Hypertension (%)	30.1	43.2	51.3	57.7	55.7	52.4
Ischaemic heart disease (%)	7.6	15.5	19.6	23.2	25.1	20.7
Heart failure/pulmonary heart disease (%)	6.7	10.1	15.4	19.5	22.9	16.9
Other chronic heart diseases (%)	7.3	10.7	15.6	19.0	23.0	16.9
Arrhythmia (%)	4.3	7.2	15.3	22.4	27.2	18.1
Cerebrovascular diseases (%)	2.8	6.0	10.1	16.6	18.8	12.9
Peripheral vascular diseases (%)	1.4	4.5	6.3	7.6	6.6	6.4
Obesity/dyslipidaemia (%)	24.4	20.4	16.9	11.3	7.0	14.2
Liver disease (%)	18.0	14.7	15.4	14.1	10.7	14.3
Chronic digestive disease (excluding liver) (%)	2.9	2.8	1.7	2.0	0.8	1.9
Chronic renal diseases (%)	2.8	2.5	7.0	9.8	13.4	8.2
Neurological and muscle disease (%)	3.8	3.8	4.0	5.9	8.4	5.3
Anaemia and coagulation disorders (%)	2.9	3.0	5.2	7.1	10.4	6.2
Thyroid disease (%)	9.0	9.6	8.1	7.4	5.9	7.8
Depression (%)	5.4	3.8	3.3	2.7	2.8	3.2
Psychiatric disease (%)	4.7	3.5	2.2	2.0	2.4	2.4
Peptic ulcer/oesophageal reflux (%)	2.4	2.0	1.4	1.4	1.5	1.5
Rheumatologic diseases (%)	0.7	1.4	1.3	1.1	0.4	1.1
HIV/AIDS (%)	0.5	0.7	0.2	0.2	0.1	0.3
Cancer (%)	3.8	5.4	8.1	8.9	5.5	7.6

Table 3. Prescription patterns during the 6 months following discharge.

		Variation among local
Prescription patterns during		health districts (range)
the 6 months following discharge	Lazio
from the index admission	region	Minimum	Maximum
LABA + ICS + LAMA (%)	30.9	15.3	54.1
LABA + ICS (%)	19.2	8.1	29.2
ICS + LAMA (%)	4.0	0.1	7.6
LABA + LAMA (%)	0.6	0.1	1.9
LABA only (%)	0.8	0.1	2.0
LAMA only (%)	5.1	0.9	10.9
ICS only (%)	14.0	4.1	29.7
No LABA, No ICS, No LAMA	25.4	13.8	39.8
SABA (%)^*	26.9	7.9	47.5

LABA, long-acting beta-agonist; ICS, inhaled corticosteroid; LAMA, long-acting muscarinic antagonist; SABA, short-acting beta-agonist.

^* SABAs may be used concomitantly with other respiratory medications.

Table 4. Determinants of adherence to long-acting bronchodilators (MPR > 80%).

Determinants	OR	95% CI	p-value
Demographics
Gender (female versus male)	0.56	0.52–0.62	<0.001
Age group (years)
55–64 (versus 45–54)	1.63	1.29–2.06	<0.001
65–74 (versus 45–54)	2.11	1.69–2.64	<0.001
75–84 (versus 45–54)	1.87	1.50–2.34	<0.001
85+ (versus 45–54)	1.10	0.85–1.41	0.464
Appropriateness of hospital management
Discharge ward
Pneumology (versus other wards)	1.19	1.04–1.35	0.010
Internal medicine (versus other wards)	0.94	0.84–1.04	0.238
Proxies of COPD severity
Respiratory failure	1.80	1.66–1.96	<0.001
Emergency visits for COPD	1.71	1.42–2.06	<0.001
Concomitant respiratory diseases
Asthma	1.91	1.55–2.35	<0.001
Acute pulmonary symptoms	1.23	1.06–1.41	0.006
Co-morbidities
Diabetes	0.73	0.66–0.81	<0.001
Ischaemic heart disease	0.91	0.82–1.01	0.084
Other chronic heart diseases	0.87	0.78–0.99	0.030
Arrhythmia	0.74	0.66–0.84	<0.001
Cerebrovascular diseases	0.69	0.60–0.79	<0.001
Peripheral vascular diseases	0.81	0.68–0.97	0.020
Liver disease	0.81	0.71–0.92	0.001
Chronic renal diseases	0.76	0.65–0.89	0.001
Neurological and muscle disease	0.63	0.51–0.79	<0.001
Depression	0.80	0.62–1.03	0.082
Psychiatric disease	0.48	0.34–0.67	<0.001
Rheumatologic/diffuse disease of connective tissue	0.68	0.45–1.04	0.079
General practitioner characteristics
Gender (female versus male)	1.00	0.91–1.10	0.991
Age (1-year age increment)	1.00	0.99–1.01	0.492
Organisational arrangement
Association (versus none)	1.02	0.89–1.16	0.774
Network (versus none)	1.08	0.95–1.23	0.232
Group practice (versus none)	1.12	1.01–1.24	0.044

Figure 3. Percentages of adherence to long-acting bronchodilator therapy by local health district.

Table 5. The trade-off between hospital of discharge and primary care providers.

	Median odds ratios
Levels of health care system	Logistic multilevel model including the primary care levels	Cross-classified model including both the primary care and the hospital of discharge levels
General practitioner	1.28 (95% CI: 1.15–1.52) p = 0.035	1.22 (1.10–1.51) p = 0.086
Local health district	1.21 (1.15–1.30) p = 0.001	1.05 (1.01–1.72) p = 0.345
Hospital of discharge	Not included	1.38 (1.29–1.50) p < 0.001
AIC	14916.76	14815.51

Median odds ratios were calculated controlling for patient characteristics.

Primary care levels: general practitioner and local health district.

AIC, Akaike Information Criterion.

Table 6. Sensitivity analysis (MPR > 75%): The trade-off between hospital of discharge and primary care providers.

	Median odds ratios
Levels of health care system	Logistic multilevel model including the primary care levels	Cross-classified model including both the primary care and the hospital of discharge levels
General practitioner	1.25 (95% CI: 1.13–1.51) p = 0.050	1.19 (1.07–1.56) p = 0.153
Local health district	1.19 (1.14–1.28) p = 0.002	1.04 (1.01–2.71) p = 0.382
Hospital of discharge	Not included	1.37 (1.29–1.48) p < 0.001
AIC	15225.75	15118.81

Median odds ratios were calculated controlling for patient characteristics.

Primary care levels: general practitioner and local health district.

AIC, Akaike Information Criterion.

Table

Co-morbidities	ICD-9-CM codes retrieved in the index admission and in the previous 24 months
Diabetes	250.0–250.9
Hypertension	401–405
Ischemic heart disease	410–414, 429.7
Heart failure/pulmonary heart disease	428, 416.9
Other chronic heart diseases	429 (excluding 429.7)093.2, 394–397.1, 424, 746.3–746.6, V42.2, V43.3, 393, 397.9, 398, 423, 391, 420, 421, 422, 425, 745, V15.1, V42.2, V43.2,V45.0, V45.81, V45.82Procedures: 36.1, 36.0, 35, 37.0, 37.1, 37.3, 37.4, 37.5, 37.6, 37.9
Arrhythmia	426.0, 426.10, 426.12, 426.13, 426.7, 426.9, 427, 785.0, 996.01, 996.04, V45.0, V53.3
Cerebrovascular diseases	430–438
Peripheral vascular diseases	440–448, 557, 093.0
Obesity/dyslipidaemia	278.0, 272
Liver disease	456.0–456.2 570–573 V42.7
Chronic digestive disease (excluding liver)	070, 577.0–577.9, 555, 556
Chronic renal diseases	582–588, V42.0, V45.1, V56Procedures: 38.95, 39.95, 54.98, 55.6
Neurological and muscle disease	334.1, 342, 343, 344, 331, 332, 333.4, 333.5, 334–335, 336.2, 340, 341, 345, 348.1, 348.3, 784.3, 356–359
Anemia and coagulation disorders	280, 281, 285.9, 286, 287.1, 287.3–287.5
Thyroid disease	240–246
Depression	300.4, 301.12, 309.0, 309.1, 311
Psychiatric disease	293.8, 295–298, 299.1, 290.0–290.4, 294.1, 331.0
Peptic ulcer/oesophageal reflux	531–534, 530.81
Rheumatologic disease of connective tissue	710, 714
HIV AIDS/disorders involving immune mechanism	042, 279
Cancer	140.0–208.9, V10