Determinants of medical prescriptions for COPD care: an analysis of the EPOCONSUL clinical audit

Figures & data

Table 1 Demographic and clinical characteristics of COPD participants

Characteristics	Average	IHR	p-valuea
Gender (male)	3,823 (85.9)	60.0–100	<0.001
Age (years)	69.7 (9.7)	63.0–75.4	<0.001
Active smokers (n)	1,029 (23.1)	6.5–38.1	<0.001
Tobacco exposure (pack-years)	56.1 (33.7)	28.3–106.3	<0.001
Body mass index (kg/m^2)	28.0 (5.4)	25.2–38.5	<0.001
Comorbidities (Charlson)	2.9 (2.1)	1.7–4.7	<0.001
FVC (%)	77.4 (20.9)	49.0–117	<0.001
FEV1 (%)	54.0 (18.5)	36.0–86.0	<0.001
FEV1 reversibility (%)	9.7 (9.5)	3.1–15.4	<0.001
FEV1/FVC (%)	52.3 (11.7)	65–47.9	<0.001

Notes:

a Calculated for variability with chi-squared test of ANOVA depending on the nature of the variable. Values are expressed as mean (standard deviation) or absolute (relative) frequencies according to the nature of the variable.

Abbreviations: ANOVA, analysis of variance; FEV₁, forced expiratory volume in 1 second; FVC, forced vital capacity; IHR, interhospital range.

Figure 1 Distribution of inhaled treatments in the EPOCONSUL cohort.

Note: Percentages refer to the complete cohort.
Abbreviations: ICS, inhaled corticosteroid; LABA, long-acting beta 2 agonists; LABD, long-acting bronchodilator; LAMA, long-acting muscarinic antagonists.

Figure 2 Distribution of oral treatments in the EPOCONSUL cohort.

Note: Percentages refer to the number of patients in each inhaled treatment group.
Abbreviations: ICS, inhaled corticosteroid; LABA, long-acting beta 2 agonists; LABD, long-acting bronchodilator; LAMA, long-acting muscarinic antagonists.

Figure 3 Distribution of inhaled treatments in the EPOCONSUL cohort according to GOLD 2017 patient types A–D.

Note: Percentages refer to the complete cohort.

Abbreviations: CAT, COPD Assessment Test; GOLD, Global Initiative for Obstructive Lung Disease; ICS, inhaled corticosteroid; LABA, long-acting beta 2 agonists; LABD, long-acting bronchodilator; LAMA, long-acting muscarinic antagonists; mMRC, modified Medical Research Council scale.

Figure 4 Distribution of oral therapies in the EPOCONSUL cohort according patient groups by GOLD 2017 patient types A–D.

Note: Percentages refer to the number of patients in each treatment.
Abbreviations: CAT, COPD Assessment Test; GOLD, Global Initiative for Obstructive Lung Disease; ICS, inhaled corticosteroid; LABA, long-acting beta 2 agonists; LABD, long-acting bronchodilator; LAMA, long-acting muscarinic antagonistsm; mMRC, modified Medical Research Council scale.

Table 2 Description of treatment changes during the audited visit

Basal treatment	No change	Step up		Similar	Step down		Others: not specified
	n (%;a %b)	Change	n (%;a %b)	n (%,a %b)	Change	n (%a; %b)	n (%a; %b)
No inhaled treatment (n = 124)c	88 (71.0; 2.0)	Increase ICS	2 (1.6; 0.04)	0	Decrease ICS	3 (2.4; 0.1)	6 (4.8; 0.1)
		Increase BD	19 (15.3; 0.4)		Decrease BD	5 (4.0; 0.1)
		Add roflumilast	1 (0.8; 0.02)		Discontinue roflumilast	0
One LABD (n = 511)	430 (84.1; 9.7)	Increase ICS	14 (2.7; 0.3)	11 (2.2; 0.2)	Decrease ICS	0	21 (4.1; 0.5)
		Increase BD	27 (5.3; 0.6)		Decrease BD	8 (1.6; 0.2)
		Add roflumilast	0		Discontinue roflumilast	0
ICS alone (n = 5)	3 (60.0; 0.1)	Increase ICS	1 (20.0; 0.02)	0	Decrease ICS	0	1 (20.0; 0.02)
		Increase BD	0		Decrease BD	0
		Add roflumilast	0		Discontinue roflumilast	0
Two LABD (n = 991)	744 (75.1; 16.7)	Increase ICS	30 (3.0; 0.7)	80 (8.1; 1.8)	Decrease ICS	0	52 (5.2; 1.2)
		Increase BD	60 (6.1; 1.3)		Decrease BD	21 (2.1; 0.5)
		Add roflumilast	4 (0.4; 0.1)		Discontinue roflumilast	0
LABD–ICS (n = 389)	284 (73.0; 6.3)	Increase ICS	8 (2.1; 0.2)	13 (3.3; 0.3)	Decrease ICS	15 (3.9; 0.3)	17 (4.4; 0.4)
		Increase BD	35 (9.0; 0.8)		Decrease BD	14 (3.6; 0.3)
		Add roflumilast	2 (0.5; 0.04)		Discontinue roflumilast	1 (0.3; 0.02)
Triple therapy (n = 2,428)	1,945 (80.1; 43.1)	Increase ICS	29 (1.2; 0.6)	134 (5.5; 3.0)	Decrease ICS	72 (3.0; 1.6)	130 (5.4; 2.9)
		Increase BD	54 (2.2; 1.2)		Decrease BD	31 (1.3; 0.7)
		Add roflumilast	21 (0.9; 0.5)		Discontinue roflumilast	12 (0.5; 0.3)
Total (n = 4,448)	3,494 (78.6)	Increase ICS	84 (1.9)	238 (5.4)	Decrease ICS	90 (2.0)	227 (5.1)
		Increase BD	195 (4.4)		Decrease BD	79 (1.8)
		Add roflumilast	28 (0.6)		Discontinue roflumilast	13 (0.3)

Notes:

a Percentage within the basal treatment group.

b Percentage within the whole cohort.

c Patients not receiving inhaled medication or with no information in the medical record. An increase reflects an augment in the number or the dose of the drugs. A decrease denotes the decrement in the number or the dose of the drugs.

Abbreviations: BD, bronchodilators; ICS, inhaled corticosteroid; LABD, long-acting bronchodilator.

Table 3 Multivariate analysis with factors associated with stepping up

Factors	Crude		Adjusted
	OR	95% CI	OR	95% CI
Chronic bronchitis	1.298	1.029–1.638	1.315	0.995–1.635
Asthma-like symptoms	1.479	1.157–1.891	1.315	1.010–1.712
Positive BDT	2.397	1.598–3.596	2.119	1.393–3.224
No inhaled treatment	3.057	1.899–4.921	1.938	1.182–3.175
Triple therapy	0.401	0.314–0.511	0.370	0.285–0.479
Phenotype: ACO	1.823	1.256–2.647	1.900	1.265–2.854
Phenotype: frequent exacerbator with chronic bronchitis	1.557	1.120–2.164	2.148	1.498–3.082
Time since previous visit (months)	1.000	1.000–1.001	1.000	1.000–1.001

Abbreviations: ACO, asthma and COPD overlap; BDT, bronchodilator test; CI, confidence interval; OR, odds ratio.

Table 4 Multivariate analysis with factors associated with stepping down

Factors	Crude		Adjusted
	OR	95% CI	OR	95% CI
Latest available spirometry: FEV1 (%)	1.008	0.974–1.043	1.025	1.010–1.040
Current spirometry: FVC <80%	1.765	1.150–2.710	2.307	1.193–4.463
ICS–LABD treatment	2.148	1.431–3.224	12.467	5.262–29.538
Triple inhaled therapy	1.449	1.066–1.970	6.546	2.983–14.368
Phenotype: nonexacerbator	2.110	1.539–2.894	2.571	1.501–4.403
COPD-dedicated outpatient clinic	1.585	1.151–2.183	1.701	0.967–2.994

Abbreviations: CI, confidence interval; FEV₁, forced expiratory volume in 1 second; FVC, forced vital capacity; ICS, inhaled corticosteroid; LABD, long-acting bronchodilator; OR, odds ratio.