Economic impact of delaying initiation with multiple-inhaler maintenance triple therapy in Spanish patients with chronic obstructive pulmonary disease

Figures & data

Figure 1 Study design.

Abbreviation: MITT, multiple-inhaler triple therapy.

Table 1 Unit costs

Healthcare resources	Unit costs (€)
Medical Visits
Medical visit to primary care	23.19
Medical visit to emergency department	117.53
Medical visit to secondary care^a	67.50
Hospitalization (1 day)	320.90
Complementary tests
Laboratory tests	22.30
Conventional radiology	18.50
Diagnostic/therapeutic tests	37.12
Spirometry	15.00
Computerized axial tomography	92.00
Magnetic resonance	154.00
Bronchodilator tests	56.00
Pharmacologic treatment	PTP+VAT

Notes: Values are expressed in €2017. ^aOnly pulmonologist and internal medicine were considered. Data from analitic accounting of centers included in the RedISS database.¹²

Abbreviations: PTP, price to public; VAT, value added tax.

Table 2 Baseline demographics and clinical characteristics of the study sample and per study groups

Study group	Total N=1,280 (100%)	Early N=788 (61.6%)	Late N=492 (38.4%)	P
Socio-demographic characteristics
Age (years), mean (SD, SE)	73.2 (10.4; 0.36)	73.3 (10.2; 0.38)	73.0 (10.7; 0.30)	0.579
40–64 years	20.5%	20.1%	21.3%
65–74 years	30.5%	30.5%	30.7%
≥75 years	48.9%	49.5%	48.0%
Gender (male)	77.9%	78.9%	76.2%	0.255
Retiree status	85.2%	85.8%	84.1%	0.422
General comorbidity
Charlson index score, mean (SD, SE)	0.9 (0.8; 0.01)	0.9 (0.9; 0.01)	0.9 (0.8; 0.01)	0.629
Number of diagnoses, mean (SD, SE)	3.8 (1.9; 0.07)	3.8 (1.9; 0.08)	3.7 (1.9; 0.05)	0.455
1	9%	8.8%	9.3%
2	16.3%	15.1%	18.1%
3	18.5%	19.4%	17.1%
4	19.9%	17.9%	23.2%
≥5	36.3%	38.8%	32.3%
Associated comorbidities
Hypertension	59.0%	59.4%	58.3%	0.708
Type 2 diabetes mellitus	32.7%	33.5%	31.5%	0.459
Dyslipidemia	50.2%	50.6%	49.4%	0.665
Obesity	35.0%	36.2%	33.1%	0.268
Active smoker	14.1%	14.1%	14.2%	0.976
Ischemic cardiomyopathy	19.2%	19.7%	18.5%	0.604
Cerebrovascular accident	13.3%	13.6%	12.8%	0.691
Cardiac insufficiency	18.0%	17.9%	18.0%	0.960
Renal insufficiency	12.6%	12.4%	12.8%	0.847
Depressive syndrome	23.6%	23.5%	23.8%	0.851
Malignant neoplasms	15.8%	15.1%	16.9%	0.399
Osteoporosis	15.7%	15.4%	16.3%	0.655
Clinical characteristics
Time since diagnosis (years), mean (SD, SE)	17.1 (3.9; 0.15)	17.2 (4.5; 0.13)	17.0 (2.9; 0.12)	0.404
BMI, kg/m^2, mean (SD, SE)	28.8 (5.2; 0.18)	28.9 (5.1; 0.20)	28.7 (5.2; 0.12)	0.573
FEV1, % (SD, SE)	54.1 (14.4; 0.51)	54.0 (14.3; 0.64)	54.4 (14.4; 0.40)	0.649
Moderate	58.7%	57.9%	60.0%
Severe	38.8%	40.0%	37.0%
Very severe	2.5%	2.2%	3.0%
Exacerbation events in previous 12 months
Moderate or severe	37.0%	35.4%	39.0%	0.194
Moderate	36.7%	34.8%	38.5%	0.147
Severe	12.8%	11.3%	14.2%	0.153
Treatment persistence
ICS/LABA plus LAMA	68.6%	68.8%	67.3%	0.668
LAMA/LABA plus ICS	67.9%	67.2%	69.3%	0.728
ICS plus LAMA plus LABA	67.1%	67.5%	66.4%	0.831

Note: Values are expressed as percentage or mean (SD; SE).

Abbreviations: BMI, body mass index; FEV1, forced expiratory volume in one second; SD, standard deviation; SE, standard error; ICS, inhaled corticosteroid; LABA, long-acting β2 agonist; LAMA, long-acting muscarinic antagonist.

Table 3 Healthcare resource use during 12-month follow-up period per study group

Study group	Early N=788 (61.6%)	Late N=492 (38.4%)	P
Primary care visits	12.8 (11.8; 0.42)	15.8 (13.8; 0.52)	<0.001
Laboratory tests	0.6 (0.9; 0.04)	0.8 (1.1; 0.05)	0.002
Chest radiology	0.3 (0.8; 0.02)	0.5 (0.8; 0.03)	<0.001
Complementary tests	1.7 (1.5; 0.05)	1.9 (1.5; 0.06)	0.020
Hospitalization	0.1 (0.3; 0.01)	0.1 (0.4; 0.01)	0.011
Secondary care visits	1.6 (1.6; 0.05)	1.9 (1.8; 0.08)	0.001
Emergency visits (hospital)	0.3 (0.8; 0.02)	0.5 (0.8; 0.03)	<0.001

Note: Values are expressed as mean (SD; SE).

Abbreviations: SD, standard deviation; SE, standard error.

Table 4 Health care costs per study group

Study group	Early N=788 (61.6%)	Late N=492 (38.4%)	P
Uncorrected costs (€)
Costs in primary care	1,505 (527; 18.7)	1,495 (563; 25.4)	0.742
Visits	294 (272; 9.6)	364 (318; 14.3)	<0.001
Laboratory tests	30 (42; 1.4)	37 (49; 1.2)	0.002
Conventional radiology	6 (14; 0.5)	10 (16; 0.6)	<0.001
Complementary tests	54 (45; 1.6)	60 (48; 2.1)	0.020
Pharmacologic treatment	1,122 (354; 9.5)	1,024 (364; 9.9)	<0.001
Costs in secondary care	317 (737; 26.2)	464 (899; 40.5)	0.002
Hospitalization	173 (644; 22.9)	277 (798; 35.9)	0.011
Visits	104 (104; 3.7)	125 (117; 5.2)	0.001
Emergency visits	41 (95; 3.3)	61 (96; 4.3)	<0.001
Total uncorrected costs	1,823 (1,078; 38.4)	1,959 (1,265; 57.0)	0.041
Corrected costs^a (€)
Primary care costs	1,500	1,471	0.367
95% CI	1,459–1,542	1,420–1,521
Secondary care costs	361	464	0.042
95% CI	292–428	381–546
Total corrected costs	1,861	1,935	0.046
95% CI	1,766–1,956	1,820–2,049

Notes: Uncorrected costs are expressed as mean (SD; SE). ^aANCOVA model, the contrasts are based on the comparison by linear independent pairs between the estimated marginal means. Variables are gender, age, Charlson index score, time from diagnosis, and number of exacerbations.

Abbreviations: CI, confidence interval; SD, standard deviation; SE, standard error.

Table 5 Exacerbations during 12-month follow-up period per study group

Study group	Early N=788 (61.6%)	Late N=492 (38.4%)
Patients with exacerbations	28.0%	36.4%	0.002
Exacerbation rate per person per year	0.5 (1.0; 0.01)	0.6 (1.0; 0.01)	0.022
0	72.0%	63.6%
1	14.3%	16.3%
2	6.5%	14.0%
>3	7.2%	6.1%
Patients with moderate exacerbations	27.4%	36.0%	0.005
Moderate exacerbation rate per person per year	0.4 (0.8; 0.02)	0.5 (0.8; 0.02)	0.037
0	72.6%	64.0%
1	17.4%	26.2%
2	5.8%	5.7%
≥3	4.2%	4.1%
Patients with severe exacerbations	27.4%	36.0%	0.005
Severe exacerbation rate per person per year	9.0%	14.4%	0.004
0	0.1 (0.3; 0.02)	0.1 (0.4; 0.02)	0.011
1	92.5%	87.8%
2	6.0%	10.2%
Time to first exacerbation, days
Mean (SD)	148.2 (96.3)	107.1 (90.5)	<0.001
Median (IQR)	130 (66–217)	80 (28–173)

Note: Values are expressed as percentages or mean (SD; SE).

Abbreviations: IQR, interquartile range; SD, standard deviation; SE, standard error.

Figure 2 Time to first exacerbation per study group.

Ministerio de Sanidad Servicios Sociales e Igualdad. Information about the products included in the pharmaceutical provision of the SNS (dispensable through pharmacies). 2018 Available from: http://www.msssi.gob.es/en/profesionales/nomenclator.do. Accessed 806, 2019.

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