Inhaled Long-acting Anticholinergics and Urinary Tract Infection in Individuals with COPD

Figures & data

Table 1. Baseline characteristics of new users of inhaled long-acting anticholinergic and inhaled corticosteroid medications before and after propensity score matching among people living in the community.

	Before matching			After matching
	Inhaled long-acting	Inhaled	Standardized	Inhaled long-acting	Inhaled	Standardized
Characteristic	anticholinergic	corticosteroid	difference	anticholinergic	corticosteroid	difference
N	23,200	36,270		18,774	18,774
Demographic characteristics
Age (Mean ± SD)	75.5 ± 6.8	74.2 ± 7.0	0.18	74.9 ± 6.6	74.9 ± 6.7	0
Female (%)	45.0	53.1	0.16	46.4	46.4	0
Socioeconomic status (%)
1 (lowest)	23.2	22.6	0.01	23.1	22.9	0
2	22.1	21.6	0.01	22.1	22.3	0
3	19.6	19.6	0	19.6	19.6	0
4	18.3	18.9	0.02	18.5	18.3	0.01
5 (highest)	16.8	17.3	0.01	16.7	16.9	0.01
Immigrant (%)	6.2	6.8	0.02	6.4	6.5	0
Urban residence (%)	80.8	83.7	0.08	81.7	81.7	0
Year of index drug claim (%)
2003	1.0	1.4	0.03	0.8	0.8	0
2004	3.5	3.8	0.02	3.4	3.4	0
2005	5.0	5.3	0.01	4.9	4.9	0
2006	7.3	7.3	0	7.4	7.4	0
2007	10.2	9.1	0.04	10.1	10.1	0
2008	11.9	12.0	0	12.1	12.1	0
2009	16.0	17.2	0.03	16.8	16.8	0
2010	45.2	43.9	0.03	44.5	44.5	0
Region of province (%)
1	8.1	6.8	0.05	7.6	7.8	0.01
2	10.1	8.3	0.06	9.4	9.5	0
3	5.3	4.4	0.04	5.0	5.0	0
4	12.1	14.1	0.06	12.8	12.8	0
5	2.6	4.1	0.08	3.0	2.8	0.01
6	5.6	5.9	0.01	5.7	5.8	0
7	6.0	6.9	0.04	6.2	6.2	0
8	7.2	9.7	0.09	7.7	7.6	0
9	12.2	12.3	0	12.4	12.6	0
10	5.7	4.9	0.04	5.4	5.4	0
11	9.2	8.8	0.01	9.2	9.1	0
12	5.1	3.9	0.06	4.7	4.5	0.01
13	8.0	7.4	0.02	8.1	8.1	0
14	2.7	2.5	0.01	2.8	2.7	0.01
COPD characteristics
COPD duration (%)
1 year or less	28.4	21.6	0.16	25.8	25.6	0
1 to 5yrs	38.0	35.3	0.06	37.3	38.4	0.02
over 5yrs	33.6	43.1	0.2	36.9	36.0	0.02
Previous spirometry (%)	58.6	46.9	0.24	55	56	0.02
Number of primary care visits in previous year, Median (interquartile range)	6 (3–10)	7 (4–10)	0.08	6 (4–10)	6 (4–10)	0.02
COPD Specialist visit^a (%)	65.0	65.2	0	65.1	65.7	0.01
Influenza vaccination (%)	57.2	57.0	0	56.8	56.9	0
Previous or co-existing medical conditions (%)
Asthma	16.3	27.7	0.27	18.2	18.2	0
Lung cancer	3.0	2.2	0.05	2.7	2.7	0
Heart failure	24.0	20.7	0.08	22.9	22.6	0.01
Arrhythmia	9.5	8.3	0.04	9.2	9.1	0
Coronary artery disease	13.0	11.4	0.05	12.7	12.8	0
Stroke	2.9	2.5	0.03	2.8	2.6	0.01
Hypertension	74.9	74.9	0	74.6	74.8	0
Non-lung cancer	9.6	9.0	0.02	9.0	9.3	0.01
Diabetes	28.8	30.9	0.05	29.7	29.8	0
Dementia	9.6	8.9	0.02	9.2	9.0	0.01
End-stage renal disease	5.0	4.3	0.03	4.7	4.6	0
Osteoporosis	6.2	5.6	0.03	5.9	5.7	0.01
Mental health encounter in previous year (%)
Hospitalizations	0.6	0.7	0.01	0.6	0.6	0
Ambulatory care visits	5.0	5.8	0.04	5.2	5.1	0
None	94.4	93.5	0.04	94.2	94.3	0
Overall level of co-morbidity (%)
Low	21.0	18.5	0.06	20.7	20.1	0.02
Moderate	39.3	39.6	0.01	39.9	40.2	0.01
High	39.7	41.9	0.04	39.4	39.7	0.01
(Continued on next page)

Table 1. (Continued)

Medication use in previous year
Number of courses of respiratory antibiotics (%)
None	48.6	41.9	0.13	47.6	47.4	0
1	24.9	26.3	0.03	25.5	25.5	0
2 or more	26.5	31.7	0.11	27.0	27.1	0
Number of courses of oral corticosteroids (%)
None	86.1	86.6	0.02	86.1	86.0	0
1	7.5	7.5	0	7.4	7.5	0
2 or more	6.4	5.8	0.02	6.5	6.5	0
Short-acting inhaled anticholinergics (%)	8.7	8.2	0.02	8.6	8.4	0.01
Short-acting inhaled beta-agonists (%)	40.2	38.6	0.03	39.4	39.7	0
Long-acting inhaled beta-agonists (%)	22.3	31.2	0.2	24.7	25.9	0.03
Methylxanthines (%)	0.8	0.7	0	0.8	0.8	0
Alpha-blockers (%)	4.8	4.2	0.03	4.4	4.5	0
Dutasteride (%)	1.6	1.5	0	1.5	1.5	0
Finasteride (%)	2.2	1.9	0.02	2.0	2.0	0
Number of different medications used, median (interquartile range)	4 (3–6)	4 (3–6)	0.03	4 (3–6)	4 (3–6)	0.01
Anticholinergic drug scale (20) (%)
0	28.0	27.9	0	27.5	28.2	0.02
1	21.9	21.9	0	21.5	20.8	0.02
2	15.9	15.7	0.01	16.4	16.2	0.01
3 or more	34.2	34.5	0.01	34.6	34.8	0
Acute events before index date
Most recent hospitalization for COPD (%)
In the past 6 months	6.9	4.5	0.11	5.9	5.5	0.02
Between 6 months and 5 years	10.2	7.1	0.11	9.3	9.3	0
Over 5 years or never	82.9	88.4	0.16	84.8	85.2	0.01
Most recent ED visit for COPD (%)
In the past 6 months	4.2	3.4	0.04	3.9	4.1	0.01
Between 6 months and 5 years	6.9	5.8	0.05	6.7	7.0	0.01
Over 5 years or never	88.9	90.8	0.06	89.3	89.0	0.01
Most recent hospitalization for COPD-related condition (%)
In the past 6 months	4.2	3.2	0.05	3.8	3.5	0.01
Between 6 months and 5 years	8.0	6.8	0.05	7.6	7.4	0.01
Over 5 years or never	87.8	90.0	0.07	88.6	89.1	0.02
Most recent ED visit for COPD-related condition
In the past 6 months	2.8	3.7	0.05	3.0	3.0	0
Between 6 months and 5 years	8.5	9.1	0.02	8.7	8.8	0
Over 5 years or never	88.7	87.1	0.05	88.3	88.3	0
Most recent hospitalization for any other reason
In the past 6 months	6.7	6.2	0.02	6.6	6.6	0
Between 6 months and 5 years	19.4	19.7	0.01	19.6	19.9	0.01
Over 5 years or never	73.8	74.1	0.01	73.8	73.5	0.01
Most recent ED visit for any other reason
In the past 6 months	14.6	15.0	0.01	14.4	14.5	0
Between 6 months and 5 years	35.3	36.7	0.03	36.0	35.5	0.01
Over 5 years or never	50.1	48.3	0.04	49.6	50.0	0.01
Other risk factors for urinary tract infections (%)
Urinary tract infections in previous year
Ambulatory	5.0	5.4	0.02	3.3	3.3	0
Requiring hospitalization or ED visit	4.5	4.0	0.02	2.7	2.7	0
Sexually transmitted disease	0.1	0.1	0	0.1	0.1	0
Antibiotic use in previous 90 days	28.2	34.1	0.13	29.0	29.3	0.01
Benign prostatic hyperplasia	3.6	3.8	0.01	3.2	3.2	0
HIV/AIDS	0.1	0.1	0	0.1	0.1	0
Nephrotic syndrome	0.0	0.1	0.01	0.0	0.0	0.01
Renal calculi	1.0	1.0	0	0.9	0.9	0
Inflammatory bowel disease	0.8	0.7	0.01	0.7	0.8	0
Splenectomy (since 1991)	0.2	0.2	0	0.2	0.2	0
Spinal cord injury	0.0	0.0	0	0.0	0.0	0.01
Multiple sclerosis	0.1	0.1	0.01	0.1	0.1	0
Paraplegia or quadriplegia	0.1	0.1	0.01	0.1	0.1	0
Previous organ transplant (except bone, cornea, and skin)	0.1	0.2	0.01	0.2	0.2	0
Urinary retention in previous year	1.5	1.1	0.03	1.1	1.1	0
Foley catheter in previous 90 days	0.6	0.6	0.01	0.6	0.6	0.01
Urogenital surgery in previous 3 months	2.2	2.1	0.01	1.9	1.9	0
General anesthetic in previous 3 months	23.2	22.5	0.02	22.8	23.1	0.01
Diabetic nephropathy	1.3	1.0	0.03	1.2	1.1	0.01

^aa COPD specialist was a pulmonologist, a general internist or a geriatrician

Table 2. Associations of health outcomes in new users of inhaled, long-acting anticholinergics compared with new users of inhaled corticosteroids in the matched community group.

	Inhaled, long-acting	Inhaled corticosteroid		Propensity-score-matched regression
	anticholinergic cohort	cohort		Hazards ratio^a (95%
Outcomes	had outcome (%)	had outcome (%)	Absolute difference, %	confidence interval)
Outcomes at 30 days
Urinary tract infection ambulatory care visit followed by a prescription for an antibiotic	74 (0.39)	66 (0.35)	0.04	1.12 (0.81–1.56)
Urinary tract infection ambulatory care visit	110 (0.59)	87 (0.46)	0.13	1.27 (0.96–1.68)
Urinary tract infection emergency department visit	51 (0.27)	42 (0.22)	0.05	1.22 (0.81–1.83)
Outcomes at 180 days
Urinary tract infection ambulatory care visit followed by a prescription for an antibiotic	453 (2.42)	435 (2.32)	0.10	1.06 (0.93–1.21)
Urinary tract infection ambulatory care visit	493 (2.63)	483 (2.58)	0.05	1.04 (0.92–1.17)
Urinary tract infection emergency department visit	251 (1.34)	237 (1.26)	0.06	1.08 (0.90–1.28)

^aReflects the risk of outcome in new users of inhaled, long-acting anticholinergics compared with new users of inhaled corticosteroids.

Table 3. Stratified associations of having an ambulatory care visit for a urinary tract infection ambulatory care visit followed by a prescription for an antibiotic in new users of inhaled, long-acting anticholinergics compared with new users of inhaled corticosteroids in the community group.

			Inhaled, long-acting	Inhaled corticosteroid		Propensity-score-matched
			anticholinergic cohort	cohort		regression Hazards ratio^a
Stratifying characteristics	Strata	n	had outcome (%)	had outcome (%)	Absolute difference, %	(95% Confidence interval)
Outcomes at 30 days
Sex	Male	20,134	40 (0.40)	23 (0.23)	0.17	1.75 (1.05–2.92)
	Female	17,414	34 (0.39)	43 (0.49)	0.10	0.79 (0.51–1.23)
Previous urinary tract infection	Yes	2,252	19 (1.69)	15 (1.33)	0.36	1.27 (0.66–2.46)
	No	35,296	55 (0.31)	51 (0.29)	0.02	1.08 (0.74–1.58)
Anticholinergic burden	High	19,166	51 (0.53)	38 (0.40)	0.13	1.35 (0.89–2.04)
	Low	18,382	23 (0.25)	28 (0.30)	0.05	0.82 (0.47–1.43)
Outcomes at 180 days
Sex	Male	20,134	217 (1.08)	188 (0.93)	0.15	1.18 (0.98–1.43)
	Female	17,414	236 (1.36)	247 (1.42)	0.04	0.97 (0.81–1.15)
Previous urinary tract infection	Yes	2,252	117 (5.20)	127 (5.64)	0.44	0.94 (0.74–1.19)
	No	35,296	336 (0.95)	308 (0.87)	0.08	1.11 (0.95–1.29)
Anticholinergic burden	High	19,166	269 (1.40)	262 (1.37)	0.03	1.04 (0.89–2.04)
	Low	18,382	184 (1.00)	173 (0.94)	0.06	1.08 (0.88–1.32)

^aReflects the risk of outcome in new users of inhaled, long-acting anticholinergics compared with the new users of inhaled corticosteroids.

The Johns Hopkins University ACG Case-Mix System. Version 8.0. Baltimore, U.S.A.: The John Hopkins University, 2006.

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