Determinants for changing the treatment of COPD: a regression analysis from a clinical audit

Figures & data

Table 1 Clinical characteristics of the audited cases (n=565)

Variable	Averagea	Interhospital range	P-valueb
Age (years)	68.6 (9.7)	66.9–69.8	NS
Male sex (n)	480 (85.0)	47.4–94.8	<0.001
Current smokers (n)	131 (23.2)	16.3–36.1	<0.001
Tobacco history (pack-year)	55.2 (31.1)	42.5–65.7	<0.001
Comorbidities (Charlson)	2.1 (1.5)	1.7–2.4	NS
Psychiatric comorbidities (n)	116 (20.5)	12.3–87.7	NS
Cardiovascular comorbidities (n)	151 (26.7)	18.2–38.9	NS
Previous neoplasms (n)	80 (14.2)	5.3–21.5	NS
Time from diagnosis (years)	5.6 (6.1)	1.1–6.9	<0.001
Exacerbations in the previous year (n)	0.9 (1.3)	0.5–1.3	NS
Hospitalizations in the previous year (n)	0.2 (0.6)	0.04–0.37	<0.001
Body mass index (kg/m^2)	28.2 (5.3)	27.7–29.6	0.007
FVC (%)	75.3 (20.8)	63.7–104.7	0.001
FEV1 (%)	52.5 (19.6)	26.3–59.1	0.017

Notes:

a Average value is expressed as mean (standard deviation) or absolute (relative) frequencies, depending on the nature of the variable;

b calculated for the variability between centers using ANOVA or chi-square test, depending on the nature of the variable.

Abbreviations: FVC, forced vital capacity; FEV₁, forced expiratory volume in 1 second; NS, not significant; ANOVA, analysis of variance.

Table 2 Description of treatment changes

Treatment step-up (n=99)		Treatment step-down (n=55)		Treatment change (n=45)
LAMA added:	32 (32.4)	LAMA discontinuation:	10 (18.2)	Change of LAMA	25 (55.6)
LAMA added	29 (29.3)			Change of LAMA for LABA	2 (4.4)
LAMA-LABA added	3 (3.0)
LABA added:	26 (26.1)	LABA discontinuation:	5 (9.1)	Change of LABA for LAMA	2 (4.4)
LABA added	14 (14.1)	LABA discontinuation	3 (5.5)
LAMA-LABA added	3 (3.0)	FDC discontinuation	6 (10.9)
ICS change for FDC	2 (2.0)	Change FDC for LAMA	3 (5.5)
LAMA change for FDC	3 (3.0)
FDC added	4 (4.0)
ICS added:	19 (19.1)	ICS discontinuation:	33 (60.0)	Change of FDC	7 (15.6)
ICS added	5 (5.1)	ICS discontinuation	24 (43.6)	Change of FDC for LABA-LAMA	4 (8.9)
Change LABA for FDC	7 (7.1)	FDC discontinuation	6 (10.9)
Change LAMA for FDC	3 (3.0)	Change FDC for LAMA	3 (5.5)
FDC added	4 (4.0)
Oral treatments added:		Oral treatments discontinuation		Change theophylline for roflumilast	2 (4.4)
Roflumilast added	17 (17.1)	Roflumilast discontinuation	10 (18.2)	Other changes	8 (17.8)
Mucolytic added	8 (8.1)	Mucolytic discontinuation	3 (5.5)
Antibiotic added	7 (7.1)	Antibiotic discontinuation	2 (3.6)
Theophylline added	6 (6.1)	Theophylline discontinuation	8 (14.5)

Note: Values expressed as absolute (relative) frequencies.

Abbreviations: LAMA, long-acting muscarinic antagonists; LABA, long-acting β₂ agonist; ICS, inhaled corticosteroids; FDC, fixed-dose combination of an inhaled steroid and a long-acting β₂ agonist.

Table 3 Multivariate analysis indicating variables associated with an increased probability of stepping up treatment

Variable	Crude		Adjusted
	OR	95% CI	OR	95% CI
Center 8	0.262	0.062–1.109	0.184	0.039–0.871
Center 9	2.129	1.239–3.659	1.864	1.017–3.417
Acute myocardial infarction	1.757	0.933–3.307	1.968	0.969–3.994
Chronic bronchitis	1.874	1.202–2.922	1.824	1.108–3.001
Exacerbations 1–2/year	2.233	1.344–3.710	2.696	1.544–4.707
Exacerbations 3 or more/year	3.484	1.718–7.064	5.235	2.280–12.018
Tiotropium	0.343	0.220–0.535	0.368	0.228–0.595
ICS-LABA combination	0.353	0.227–0.550	0.260	0.156–0.431

Abbreviations: OR, odds ratio; CI, confidence interval; ICS, inhaled corticosteroids; LABA, long-acting β₂ agonist.

Table 4 Multivariate analysis indicating variables associated with an increased probability of stepping down treatment

Variable	Crude		Adjusted
	OR	95% CI	OR	95% CI
Receiving antibiotics	4.366	1.299–14.678	15.909	2.812–90.025
Receiving any ICS	3.906	1.640–9.302	4.287	1.351–13.598
FEV1 (%)	1.021	1.002–1.040	1.033	1.011–1.055

Abbreviations: OR, odds ratio; CI, confidence interval; ICS, inhaled corticosteroids; FEV₁, forced expiratory volume in 1 second.

Table 5 Multivariate analysis indicating variables associated with an increased probability of discontinuing inhaled steroids

Variables	Crude		Adjusted
	OR	95% CI	OR	95% CI
Center 6	2.205	1.011–4.813	6.030	1.931–18.835
GOLD A	2.265	0.974–5.267	1.667	0.584–4.818
GOLD B	0.401	0.088–1.814	0.134	0.020–0.891
GOLD C	0.664	0.250–1.763	0.342	0.100–1.167
GOLD D	0.250	0.071–0.878	0.126	0.026–0.611
Asthma-like symptoms	0.364	0.108–1.235	0.243	0.060–0.982
Pneumococcal vaccine	0.230	0.051–1.040	0.191	0.035–1.034
Not combined LABA+LAMA	3.045	1.143–8.114	5.753	1.717–19.277
Mild FEV1 impairment	1.333	0.254–7.007	0.452	0.063–3.260
Moderate FEV1 impairment	0.197	0.050–0.768	0.110	0.022–0.563
Severe FEV1 impairment	0.211	0.058–0.770	0.174	0.034–0.881
Very severe FEV1 impairment	0.063	0.007–0.600	0.050	0.004–0.640

Abbreviations: OR, odds ratio; CI, confidence interval; LAMA, long-acting muscarinic antagonists; LABA, long-acting β₂ agonist; GOLD, Global initiative for Obstructive Lung Disease; FEV₁, forced expiratory volume in 1 second.