Physician-Patient Concordance in Pharmacological Management of Patients with COPD

Figures & data

Figure 1. Patient study cohorts.

Table 1. Demographic and clinical characteristics of patients

Characteristic (N=805)	Number (%)
Age
• <65 years	307 (38.1)
• 65 year and older	498 (61.9)
Gender
• Female	360 (44.7)
• Male	443 (55.0)
• Missing	2 (0.3)
Smoking status
• Current smoker	212 (26.3)
• Ex-smoker	593 (73.7)
Depression
• Physician-confirmed diagnosis	125 (15.5)
• No physician-confirmed diagnosis	680 (84.5)
MMAS-8
• Low	206 (25.6)
• Medium	150 (18.6)
• High	18 (2.2)
• Missing	430 (53.4)
Physician managing patient's COPD
• Primary care	259 (32.2)
• Pulmonologist	110 (13.7)
• Primary care + pulmonologist	425 (53.1)
• Missing	11 (1.4)
Routine visits in the last 12 months
• 1 to 2	292 (36.3)
• ³3	498 (61.9)
• Missing	15 (1.9)
Exacerbation history
• None or no HCP intervention required	529 (65.7)
• HCP intervention (primary care visit, emergency department visit, or hospitalization)	269 (33.0)
• Missing	7 (0.9)
Treatment
• Monotherapy	234 (29.1)
• Dual therapy	189 (23.5)
• Triple therapy	268 (33.3)
• Missing	114 (14.2)

Abbreviations: COPD, chronic obstructive pulmonary disease; MMAS-8, Morisky Medication Adherence Scale; HCP, healthcare provider.

Table 2. Concordance between physician and patient ratings for disease characteristics

Disease Characterisitic	Number of Matched Surveys	Kappa Statistic (κ)
Time of day patient affected by COPD	400	0.47
Symptoms experienced in the last 4 weeks
• No symptoms	398	0.67
• Shortness of breath when resting	398	0.63
• Shortness of breath when exercising	398	0.57
• Shortness of breath when exposed to trigger	398	0.49
• Bronchospasm/sudden chest tightening	398	0.41
• A tight feeling in the chest	398	0.46
• Cough	398	0.57
• Coughing up blood	398	0.22
• Excess sputum production/clearance	398	0.53
• Wheezing	398	0.53
Frequency of symptoms in the last 4 weeks
• First thing in the morning	412	0.57
• Daytime	418	0.61
• Last thing in the evening	367	0.58
• Night time	366	0.59
• MRC dyspnea scale	401	0.59
Disease impact
• Getting up and ready for the day	430	0.57
• Patient's normal daily activities	433	0.58
• Patient's mood	417	0.57
• Personal relationships	413	0.54
• Leisure/personal time	413	0.59
• Work	126	0.57
• Sleep	410	0.58
Perceived severity of COPD	445	0.57

Results κ < 0.0 indicate no agreement, 0.00 to 0.20 = slight agreement, 0.21 to 0.40 = fair agreement, 0.41 to 0.60 = moderate agreement, 0.61 to 0.80 = substantial agreement, and 0.81 to 1.00 = almost perfect agreement (46).

Abbreviations: COPD, chronic obstructive pulmonary disease; MRC, Modified Medical Research Council Dyspnea Scale.

Table 3. Type of treatment associated with demographic and clinical characteristics

	Type of Therapy, %			P-value for Comparisons
Characteristic(N = 805)	Mono(n = 234)	Dual(n = 189)	Triple(n = 268)	Mono vs Dual	Mono vs Triple	Dual vs Triple
Age, years				1.000	0.0338	0.038
• <65	41.0	41.3	29.9
• 65 or older	59.0	58.7	70.2
• Mean (SD)	66.3 (9.9)	66.4 (10.6)	69.2 (9.4)
Gender				1.000	1.000	1.000
• Female	42.7	45.0	46.3
• Male	56.8	55.0	53.4
• Missing	0.4	0.0	0.4
Smoking status				0.695	0.321	0.012
• Current smoker	25.6	31.2	19.4
• Ex-smoker	74.4	68.8	80.6
Depression
• Physician-confirmed diagnosis	11.1	20.6	16.8	0.029	0.220	0.982
MMAS-8				1.000	0.974	1.000
• High	2. 6	3.2	0.75
• Medium	18.8	16.4	18.76
• Low	25.2	27.5	28.0
• Missing (no patient survey completed)	53.0	53.0	53.0
Physician managing patient's COPD				0.113	0.132	0.053
• Primary care	32.5	37.6	25.8
• Pulmonologist	56.0	45.5	57.5
• Primary care with pulmonologist	9.4	15.9	16.0
• Missing	2.0	1.0	1.0
Routine visits in last 12 months				0.471	<0.001	0.118
• 1 to 2	42.3	34.9	26.5
• ³3	55. 6	61.9	72.8
• Missing	2.0	3.0	1.0
Exacerbation history				0.667	<0.001	<0.00
• None or no HCP intervention required	75.2	69.8	50.8			1
• HCP intervention (primary care visit, emergency department visit, or hospitalization)	23.9	29.6	48.1
• Missing	1.0	1.0	1.0

Abbreviations: COPD, chronic obstructive pulmonary disease; HCP, healthcare provider; MMAS-8, Morisky Medication Adherence Scale; Mono, monotherapy; SD, standard deviation.

Table 4. Variations in type of treatment associated with symptoms experienced in the last 4 weeks

	Type of Therapy, %*			P-value for Comparisons
Symptom(n = 691)	Mono(n = 234)	Dual(n = 189)	Triple(n = 268)	Mono vs Dual	Mono vs Triple	Dual vs Triple
• No symptoms	24.8	16.4	5.2	0.125	<0.001	<0.001
• Shortness of breath when resting	24.4	29.1	35.8	0.807	0.019	0.473
• Shortness of breath when exercising	50.9	62.4	73.5	0.053	<0.001	0.053
• Shortness of breath when exposed to trigger	11.5	18.5	24.6	0.157	<0.001	0.413
• Bronchospasm/sudden chest tightening	13.7	22.8	22.0	0.046	0.060	1.000
• A tight feeling in the chest	19.2	25.4	34.0	0.379	<0.001	0.189
• Cough	54.3	67.2	73.1	0.021	<0.001	0.630
• Coughing up blood	3.4	5.3	4.5	1.000	1.000	1.000
• Excess sputum production/clearance	27.8	32.8	41.8	0.857	0.003	0.189
• Wheezing	18.8	27.5	41.0	0.107	<0.001	0.012
• Missing	0.0	0.5	0.0	—	—	—

*The sum of the percentages exceeds 100% because respondents could indicate more than one response. Abbreviations: Mono, monotherapy.

Significant differences (P £ 0.05) shown in bold.

Table 5. Variations in type of treatment associated with time of day patient affected by COPD

	Type of Therapy, %			P-value for Comparisons
Time of Day(n = 691)	Mono(n = 234)	Dual(n = 189)	Triple(n = 268)	Mono vs Dual	Mono vs Triple	Dual vs Triple
• Daytime only	21.4	19.6	13.4	0.450	0.044	1.000
• Primarily daytime	39.3	36.5	39.9
• Equally day and night	29.5	31.2	39.9
• Primarily night time	1.7	4.8	1.5
• Night time only	0.9	2.7	0.0
• Missing	7.3	5.3	5.2

Abbreviations: Mono, monotherapy.

Significant differences (P £ 0.05) shown in bold.

Table 6. Variations in type of treatment by frequency of symptoms in the last 4 weeks

	Type of Therapy, %			P-value for Comparisons
Frequency of Symptoms(n = 691)	Mono(n = 234)	Dual(n = 189)	Triple(n = 268)	Mono vs Dual	Mono vs Triple	Dual vs Triple
Response: First thing in the morning				1.000	<0.001	<0.001
• Not at all	35.5	28.0	15.3
• Less than once per week	16.2	18.5	18.3
• Once or twice per week	17.1	17.5	24.3
• 3 to 6 times per week	18.0	20.1	17.2
• Daily	10.7	9.0	20.9
• Missing	2.6	6.9	4.1
Response: Daytime				0.070	<0.001	<0.001
• Not at all	25.6	18.0	6.7
• Less than once per week	19.2	17.5	15.7
• Once or twice per week	23.5	21.2	23.5
• 3 to 6 times per week	14.1	22.2	23.1
• Daily	14.1	16.4	28.0
• Missing	3.4	4.8	3.0
Response: Last thing in the evening				0.065	<0.001	0.004
• Not at all	49.6	38.1	23.1
• Less than once per week	13.7	13.8	20.2
• Once or twice per week	14.1	20.6	26.5
• 3 to 6 times per week	9.0	9.5	11.2
• Daily	5.6	7.9	13.1
• Missing	8.1	10.1	6.0
Response: Nighttime				0.606	<0.001	0.006
• Not at all	47.4	41.8	25.0
• Less than once per week	15.0	15.3	24.3
• Once or twice per week	12.0	16.9	23.5
• 3 to 6 times per week	10.3	10.6	11.9
• Daily	6.8%	7.9%	10.8%
• Missing	8.6%	7.4%	4.5%

Abbreviations: Mono, monotherapy.

Significant differences (P £ 0.05) shown in bold.

Table 7. Variations in type of treatment by COPD disease impact

	Type of Therapy			P-value for Comparisons
Disease Impact, mean (n = 691)	Mono(n = 234)	Dual(n = 189)	Triple(n = 268)	Mono vs Dual	Mono vs Triple	Dual vs Triple
• Getting up and ready for the day	2.6	3	3.7	0.181	<0.001	<0.001
• Normal daily activities	3	3.4	4.2	0.749	<0.001	<0.001
• Mood	2.6	2.9	3.6	0.191	<0.001	<0.001
• Personal relationships	2.3	2.6	3.2	0.593	<0.001	<0.001
• Leisure/personal time	2.7	3.2	3.8	0.139	<0.001	<0.001
• Work*	2.7	2	3.5	1.000	<0.001	<0.001
• Sleep	2.4	2.7	3.2	0.411	<0.001	0.002
• Missing, %	3.9	5.3	4.9	—	—	—

*Due to the age of the sample with 498 (61.86%) of patients 65 years or older, a large percentage of patients were no longer working. These subjects were excluded from this analysis. Abbreviations: Mono, monotherapy.

Significant differences (P £ 0.05) shown in bold.

Table 8. Variations in type of treatment by lung function and health status characteristics

	Type of Therapy, %			P-value for Comparisons
	Mono(n = 234)	Dual(n = 189)	Triple(n = 268)	Mono vs Dual	Mono vs Triple	Dual vs Triple
Most recent FEV1% predicted				0.512	<0.001	0.001
• ³80%	9.0	6.9	2.6
• £50% to <80%	38.0	32.3	37.3
• £30% to <50%	8.1	11.1	22.4
• <30%	2.1	2.7	7.8
• Missing, %	43.0	47.0	30.0
EQ-5D*				0.137	0.014	1.000
• Mean (SD)	0.8 (0.2)	0.8 (0.2)	0. 8 (0.2)
• Missing, %	48.3	42.3	47.0
WPAI*				1.000	1.000	1.000
• Mean (SD)	19.8 (22.8)	22.9 (28.7)	20.7 (15.6)
• Missing, %	76.9	85.7	89.2
CAT*				0.045	<0.001	0.049
• <10	13.3	6.9	1.9
• 10–20	18.4	21.2	16.8
• >20	20.5	29.6	33.6
• Mean	17.1	20.1	22.9
• Missing, %	48.0	42.0	48.0

*A large number of patients (n = 336) did not complete a PSC and these instruments were also not completed by these patients.

Abbreviations: CAT, COPD Assessment Test; EQ-5D, EuroQual-5 dimensions; FEV1, forced expiratory volume in 1 second; Mono, monotherapy; WPAI, Work Productivity and Activity Impairment Questionnaire.

Significant differences (P ≤ 0.05) shown in bold.

Figure 2. Variations in type of treatment by Modified Medical Research Council Dyspnea Scale. Score: 0 = Only gets breathless after strenuous exercise; 1 = Gets breathless when hurrying on level ground or walking up a slight incline; 2 = On level ground, walks slower than people of the same age because of breathlessness, or has to stop for breath when walking at own pace; 3 = Stops for breath after walking a few meters on level ground; 4 = Is too breathless to leave the house or becomes breathless when getting dressed.

Figure 3. Variations in type of treatment by physician rating of disease severity.

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