Assessing the healthcare resource use associated with inappropriate prescribing of inhaled corticosteroids for people with chronic obstructive pulmonary disease (COPD) in GOLD groups A or B: an observational study using the Clinical Practice Research Datalink (CPRD)

Abstract

BackgroundRecent recommendations from the Global Initiative for Chronic Obstructive Lung Disease (GOLD) position inhaled corticosteroids (ICS) for use in chronic obstructive pulmonary disease (COPD) patients experiencing exacerbations (≥ 2 or ≥ 1 requiring hospitalisation); i.e. GOLD groups C and D. However, it is known that ICS is frequently prescribed for patients with less severe COPD. Potential drivers of inappropriate ICS use may be historical clinical guidance or a belief among physicians that intervening early with ICS would improve outcomes and reduce resource use. The objective of this study was to compare healthcare resource use in the UK for COPD patients in GOLD groups A and B (0 or 1 exacerbation not resulting in hospitalisation) who have either been prescribed an ICS-containing regimen or a non-ICS-containing regimen.MethodsLinked data from the Clinical Practice Research Datalink (CPRD) and Hospital Episode Statistics (HES) database were used. For the study period (1 July 2005 to 30 June 2015) a total 4009 patients met the inclusion criteria; 1745 receiving ICS-containing therapy and 2264 receiving non-ICS therapy. Treatment groups were propensity score-matched to account for potential confounders in the decision to prescribe ICS, leaving 1739 patients in both treatment arms. Resource use was assessed in terms of frequency of healthcare practitioner (HCP) interactions and rescue therapy prescribing. Treatment acquisition costs were not assessed.ResultsResults showed no benefit associated with the addition of ICS, with numerically higher all-cause HCP interactions (72,802 versus 69,136; adjusted relative rate: 1.07 [p = 0.061]) and rescue therapy prescriptions (24,063 versus 21,163; adjusted relative rate: 1.05 [p = 0.212]) for the ICS-containing group compared to the non-ICS group. Rate ratios favoured the non-ICS group for eight of nine outcomes assessed. Outcomes were similar for subgroup analyses surrounding potential influential parameters, including patients with poorer lung function (FEV1 < 50% predicted), one prior exacerbation or elevated blood eosinophils.ConclusionsThese data suggest that ICS use in GOLD A and B COPD patients is not associated with a benefit in terms of healthcare resource use compared to non-ICS bronchodilator-based therapy; using ICS according to GOLD recommendations may offer an opportunity for improving patient care and reducing resource use.Electronic supplementary materialThe online version of this article (10.1186/s12931-018-0767-2) contains supplementary material, which is available to authorized users.

Treatment Patterns of New Users of Fluticasone Furoate/Vilanterol in Asthma and COPD in UK Primary Care: Retrospective Cohort Study

“…Previous studies have also demonstrated similar issues in this setting, largely regarding the overprescription of ICS/LAMA/LABA triple therapy [19]. Inappropriate ICS prescription as described here and in previous studies exposes patients to unnecessary safety issues like pneumonia [20], and also increases the healthcare resource use associated with treatment [21].…”

Inhaled Corticosteroid Treatment in Chronic Obstructive Pulmonary Disease (COPD): Boon or Bane?

“…31 In a population-based study in the UK, ICS was inappropriately prescribed in almost half of GOLD A/B patients with COPD. 6 Moreover, in this study, addition of ICS did not provide additional clinical benefit.…”

“…10,18 Moreover, management of COPD by appropriate nonpharmacologic interventions, such as smoking cessation, nutritional counseling, vaccination, and pulmonary rehabilitation, should also be considered ( Figure 2). Although use of ICS is recommended in high-risk patients or GOLD group D, 10,19 ICS are frequently inappropriately prescribed outside current treatment recommendations for patients with less severe COPD as well, 6,8 which is both not of value and potentially dangerous due to adverse effects.…”

“…5 Despite immunologic differences in disease etiology, ICS are overused in patients with COPD. [6][7][8][9] This sparks interest because they are not indicated in most patients 10 and can increase the risk of a number of adverse events including pneumonia. 11 Therefore, identifying the right patients with COPD who will benefit from ICS treatment is important.…”

Current appraisal of single inhaler triple therapy in COPD

“…Real-life observational data from a UK primary care database of GOLD A or B patients have also shown no differences in health resource use comparing open triple therapy vs LABA/LAMA. 10 The DACCORD real-life observational study from Germany looked at 377 infrequently exacerbating patients mostly GOLD B, who were switched to IND/GLY having previously been taking open triple therapy. 11 Over the 1 year of follow-up after switching, there was no increase in exacerbations while 52% had a clinically relevant improvement in COPD Assessment Test score.…”