Impact of Therapy Persistence on Exacerbations and Resource Use in Patients Who Initiated COPD Therapy

Figures & data

Figure 1 Study design.

Table 1 Characteristics of the Patients Who Initiated COPD Treatment During the Exposure Period (N=2164)

	Patients N=2164
Age, years, mean (SD)	66.0 (11.4)
Males, n (%)	1298 (60.0)
Free-access-to-care status, n (%)	110 (5.1)
Long-term disease status* or hospitalization for COPD, n (%)	202 (9.3)
Hospitalization	50 (2.3)
LTD	169 (7.8)
Comorbidities, n (%)
Cardiovascular disease	1572 (72.6)
Depression	435 (20.1)
Diabetes	397 (18.3)
Cancer	272 (12.6)
Visit to primary care practitioners, n (%)
0–4	642 (29.7)
5–9	818 (37.8)
10–14	425 (19.6)
15–20	188 (8.7)
20 and over	91 (4.2)
Visit to physicians other than primary care practitioners, n (%)	794 (36.7)
At hospital (regardless of specialty)	698 (32.3)
Respiratory physician in private practice	166 (7.7)
Number of COPD inhalers, n (%)
1	971 (44.9)
2	779 (36.0)
3	285 (13.2)
4 and over	129 (6.0)
Use of oxygen therapy, n (%)	54 (2.5)
Use of non-invasive ventilation, n (%)	62 (2.9)
Pulmonary Function Testing, n (%)	622 (28.7)

Notes: All n (%) values indicate the number (percentage) of patients. *LTD: Patients registered with long-term disease benefit from full coverage for all medical expenses, with ICD-10 diagnosis codes, start and end date of LTD.

Abbreviations: COPD, chronic obstructive pulmonary disease; LTD, long-term disease; SD, standard deviation.

Figure 2 Flow chart.

Table 2 Description of the COPD Therapies Dispensed During the Exposure Period (N=2164)

Treatment Combinations	Number	Percentage
Monotherapy	667	30.8
ICS	42	6.3
Twice-daily LABA	93	13.9
LAMA	407	61.0
Once-daily LABA	125	18.7
Dual therapy (two different molecules)*	767	35.4
ICS/twice-daily LABA	400	52.2
ICS/LAMA	37	4.8
ICS/SABA	116	15.1
Twice-daily LABA/LAMA	41	5.3
Twice-daily LABA/SABA	21	2.7
LAMA/SABA	46	6.0
LAMA/once-daily LABA	69	9.0
All dual therapies represented in less than 1% of the total number of patients	37	4.8
Triple therapy*	502	23.2
ICS/twice-daily LABA/LAMA	179	35.7
ICS/twice-daily LABA/SABA	205	40.8
All triple therapies represented in less than 1% of the total number of patients	118	23.5
Other combinations*	228	10.5
ICS/twice-daily LABA/LAMA plus SABA	83	36.4
All other combinations represented in less than 1% of the total number of patients	145	63.6

Note: *Only combinations in at least 2% of the total number of patients are detailed.

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

Figure 3 Persistence at 12 months to (A) ICS/twice-daily LABA (n=700), (B) ICS (n=344), (C) twice-daily LABA (n=306), (D) LAMA (n=874), and (E) once-daily LABA (n=265), using the Kaplan-Meier method.

Table 3 Comparison of Exacerbation Numbers Between Persistent and Non-Persistent COPD Patients During the Follow-Up Period (Generalized Linear Model)

Exacerbations	Persistent Patients (n=721)		Non-Persistent Patients (n=721)		p-value: Persistent All* vs Non-Persistent All*
	At Least One Exacerbation Per Year	All*	At Least One Exacerbation Per Year	All*	Non-Adjusted	Adjusted**
All exacerbations
N (%)	441 (100)	441 (61.2)	438 (100)	438 (60.7)	0.91	0.95
Mean (SD)	1.8 (1.1)	1.1 (1.2)	1.8 (1.1)	1.1 (1.2)
Median (IQR)	1 (1–2)	1 (0–2)	1 (1–2)	1 (0–2)
Min – Max	1–6	0 - 6	1–6	0–6
Moderate exacerbations
N (%)	432 (100)	432 (59.9)	427 (100)	427 (59.2)	0.86	0.93
Mean (SD)	1.8 (1.1)	1.1 (1.2)	1.8 (1.1)	1.1 (1.2)
Median (IQR)	1 (1–2)	1 (0–2)	1 (1–2)	1 (0–2)
Min – Max	1–6	0–6	1–6	0–6
Severe exacerbations
N (%)	22 (100)	22 (3.1)	21 (100)	21 (2.9)	0.71	-
Mean (SD)	1.2 (0.7)	0 (0.2)	1.1 (0.5)	0 (0.2)
Median (IQR)	1 (1–1)	0 (0–0)	1 (1–1)	0 (0–0)
Min – Max	1–4	0–4	1–3	0–3

Notes: *All: patients with or without exacerbation during the year. **Adjusted for the following confounding factors: number of COPD treatments, presence/absence of an LTD or COPD-related hospitalization, number of visits to a GP, occurrence of ≥1 visit to a respiratory physician in private practice or to a hospital practitioner (regardless of specialty), presence/absence of comorbidities (cardiovascular diseases, depression, cancer and diabetes), use or non-use of oxygen therapy, use or non-use of NIV.

Abbreviations: COPD, chronic obstructive pulmonary disease; GP, general practitioner; IQR, interquartile range; LTD, long-term disease; NIV, non-invasive ventilation; SD, standard deviation.

Table 4 Description of Healthcare Resource Utilization in Matched Persistent and Non-Persistent Patients During the Follow-Up Period

	Persistent Patients (n=721)		Non-Persistent Patients (n=721)
	Number (%) of Users	Mean (SD) Number of Care Events Per User	Number (%) of Users	Mean (SD) Number of Care Events Per User
Visit to:
General practitioners	695 (96.4)	8.3 (6.1)	676 (93.8)	8.1 (6.0)
Respiratory physicians	47 (6.5)	1.7 (1.2)	31 (4.3)	2.1 (2.9)
Physiotherapists	109 (15.1)	35.4 (44.7)	121 (16.8)	34.4 (40.6)
Hospital practitioners (all specialties)	247 (34.3)	3.1 (3.6)	264 (36.6)	2.9 (3.0)
Medications
Twice-daily LABA	131 (18.2)	8.9 (4.1)	70 (9.7)	5.5 (4.4)
Once-daily LABA	130 (18.0)	9.2 (4.2)	51 (7.1)	5.0 (3.6)
ICS	138 (19.1)	7.7 (8.4)	104 (14.4)	3.3 (3.5)
LAMA	419 (58.1)	9.4 (3.8)	160 (22.2)	5.4 (3.8)
ICS/twice-daily LABA FDC	258 (35.8)	8.9 (4.7)	164 (22.7)	4.8 (4.3)
Once-daily LABA/LAMA FDC	10 (1.4)	4.7 (2.6)	5 (0.7)	2.4 (1.5)
SABA	174 (24.8)	6.0 (6.8)	182 (25.2)	4.6 (5.3)
SABA/SAMA FDC	22 (3.1)	13.1 (11.9)	25 (3.5)	7.2 (10.4)
SAMA	24 (3.3)	26.0 (44.5)	11 (1.5)	22.0 (29.1)
Xanthines	10 (1.4)	17.5 (11.0)	8 (1.1)	12.3 (8.8)
Oral corticosteroids	183 (25.4)	1.7 (1.4)	182 (25.2)	1.7 (1.2)
Intramuscular corticosteroids	44 (6.1)	3.0 (2.4)	59 (8.2)	2.8 (3.5)
Respiratory antibiotics	408 (56.6)	5.1 (4.7)	411 (57.0)	5.2 (5.1)
Influenza vaccine	442 (61.3)	1.0 (0.2)	300 (41.6)	1.0 (0.2)
Pneumococcal vaccine	50 (6.9)	1.0 (0.1)	28 (3.9)	1.1 (0.3)
Medical procedures (in primary or secondary care)
Pulmonary Function Testing	237 (32.9)	2.0 (1.4)	155 (21.5)	1.9 (2.0)
X-ray and chest CT scan	277 (38.4)	2.1 (2.8)	227 (31.5)	2.0 (2.4)
Non-invasive ventilation	31 (4.3)	39.2 (22.3)	15 (2.1)	37.8 (22.3)
Oxygen therapy	17 (2.4)	34.7 (22.0)	24 (3.3)	38.4 (19.5)
Nebulizers	53 (7.4)	5.0 (5.5)	39 (5.4)	3.8 (4.4)
Hospitalizations
All hospitalizations	224 (31.1)	2.3 (3.8)	233 (32.3)	2.5 (5.3)
Hospitalizations for COPD	22 (3.1)	1.5 (0.9)	21 (2.9)	1.4 (1.1)

Abbreviations: COPD, chronic obstructive pulmonary disease; CT, computed tomography; FDC, fixed-dose combination; ICS, inhaled corticosteroid; LABA, long-acting beta-agonist; LAMA, long-acting muscarinic antagonist; SABA, short-acting beta-agonist; SAMA, short-acting muscarinic antagonist; SD, standard deviation.