Development and validation of a claims-based algorithm to identify moderate exacerbations in patients with asthma treated in the US

INTRODUCTION

Definitions of moderate asthma exacerbation have been inconsistent, making their economic burden difficult to assess. An algorithm to accurately identify moderate exacerbations from claims data is needed.

METHODS

A retrospective cohort study of Reliant Medical Group patients aged ≥18 years, with ≥1 prescription claim for inhaled corticosteroid/long-acting β2-agonist, and ≥1 medical claim with a diagnosis code for asthma was conducted. The objective was to refine current algorithms to identify moderate exacerbations in claims data and assess the refined algorithm's performance. Positive and negative predictive values (PPV and NPV) were assessed via chart review of 150 moderate exacerbations events and 50 patients without exacerbations. Sensitivity analyses assessed alternative algorithms and compared healthcare resource utilization (HRU) between algorithm-identified patients (claims group) and those confirmed by chart review (confirmed group) to have experienced a moderate exacerbation.

RESULTS

Algorithm-identified moderate exacerbations were: visit of ≤1 day with an asthma exacerbation diagnosis OR visit of ≤1 day with selected asthma diagnoses AND ≥1 respiratory pharmacy claim, excluding systemic corticosteroids, within 14 days after the first claim. The algorithm's PPV was 42%; the NPV was 78%. HRU was similar for both groups.

CONCLUSION

This algorithm identified potential moderate exacerbations from claims data; however, the modest PPV underscores its limitations in identifying moderate exacerbations, although performance was partially due to identification of previously unidentified severe exacerbations. Application of this algorithm in future claims-based studies may help quantify the economic burden of moderate and severe exacerbations in asthma when an algorithm identifying severe exacerbations is applied first.

Frequency and economic burden of exacerbations in inhaled corticosteroid/long-acting beta-agonist-treated patients with asthma: A retrospective US claims study

INTRODUCTION

Despite adherence to inhaled corticosteroid/long-acting β2-agonist (ICS/LABA) therapy, many patients with asthma experience moderate exacerbations. Data on the impact of moderate exacerbations on the healthcare system are limited. This study assessed the frequency and economic burden of moderate exacerbations in patients receiving ICS/LABA.

METHODS

Retrospective, longitudinal study analyzed data from Optum's de-identified Clinformatics® Data Mart Database recorded between October 1, 2015, and December 31, 2019. Eligibility criteria included patients ≥18 years of age with ≥1 ICS/LABA claim and ≥1 medical claim for asthma in the 12 months pre-index (first ICS/LABA claim). Primary objectives included describing moderate exacerbation frequency, and associated healthcare resource utilization (HRU) and costs. A secondary objective was assessing the relationship between moderate exacerbations and subsequent risk of severe exacerbations. Patients were stratified by moderate exacerbation frequency in the 12 months post index. Moderate exacerbations were identified using a newly developed algorithm.

RESULTS

In the first 12 months post index 61.6% of patients experienced ≥1 moderate exacerbation. Mean number of asthma-related visits was 4.1 per person/year and median total asthma-related costs was $3544. HRU and costs increased with increasing exacerbation frequency. Outpatient and inpatient visits accounted for a similar proportion of these costs. Moderate exacerbations were associated with an increased rate and risk of future severe exacerbations (incidence rate ratio, 1.56; hazard ratio, 1.51 [both p < 0.001]).

CONCLUSIONS

This study highlighted that a high proportion of patients continue to experience moderate exacerbations despite ICS/LABA therapy and subsequently experience increased economic burden and risk of future severe exacerbations.

Patterns of care in the management of high-risk COPD in the US (2011-2019): an observational study for the CONQUEST quality improvement program

Background

In this study, we compare management of patients with high-risk chronic obstructive pulmonary disease (COPD) in the United States to national and international guidelines and quality standards, including the COllaboratioN on QUality improvement initiative for achieving Excellence in STandards of COPD care (CONQUEST).

Methods

Patients were identified from the DARTNet Practice Performance Registry and categorized into three high-risk cohorts in each year from 2011 to 2019: newly diagnosed (≤12 months after diagnosis), already diagnosed, and patients with potential undiagnosed COPD. Patients were considered high-risk if they had a history of exacerbations or likely exacerbations (respiratory consult with prescribed medication). Descriptive statistics for 2019 are reported, along with annual trends.

Findings

In 2019, 10% (n = 16,610/167,197) of patients met high-risk criteria. Evidence of spirometry for diagnosis was low; in 2019, 81% (n = 1228/1523) of patients newly diagnosed at high-risk had no record of spirometry/peak expiratory flow in the 12 months pre- or post-diagnosis and 43% (n = 651/1523) had no record of COPD symptom review. Among those newly and already diagnosed at high-risk, 52% (n = 4830/9350) had no evidence of COPD medication.

Interpretation

Findings suggest inconsistent adherence to evidence-based guidelines, and opportunities to improve identification, documentation of services, assessment, therapeutic intervention, and follow-up of patients with COPD.

Funding

This study was conducted by the Observational and Pragmatic Research Institute (OPRI) Pte Ltd and was partially funded by Optimum Patient Care Global and AstraZeneca Ltd. No funding was received by the Observational & Pragmatic Research Institute Pte Ltd (OPRI) for its contribution.

Healthcare Cost and Utilization before and after Diagnosis of Pseudomonas aeruginosa among Patients with Non-Cystic Fibrosis Bronchiectasis in the U.S

Non-cystic fibrosis bronchiectasis (NCFBE) is a rare, chronic lung disease characterized by bronchial inflammation and permanent airway dilation. Chronic infections with P. aeruginosa have been linked to higher morbidity and mortality. To understand the impact of P. aeruginosa in NCFBE on health care costs and burden, we assessed healthcare costs and utilization before and after P. aeruginosa diagnosis. Using data from 2007 to 2013 PharMetrics Plus administrative claims, we included patients with ≥2 claims for bronchiectasis and >1 claim for P. aeruginosa; then excluded those with a claim for cystic fibrosis. Patients were indexed at first claim for P. aeruginosa and were required to have >12 months before and after the index P. aeruginosa. The mean differences in utilization and costs were assessed using paired Student's t-tests for statistical significance. Mean total healthcare costs per patient were $36,213 pre-P. aeruginosa diagnosis versus $67,764 post-P. aeruginosa, an increase of 87% (p < 0.0001). Inpatient costs represented the largest proportion of total healthcare costs post-P. aeruginosa (54%) with an increase of four hospitalizations per patient (p < 0.0001). NCFBE patients with evidence of P. aeruginosa incur substantially greater healthcare costs and utilization after P. aeruginosa diagnosis. Future research should explore methods of earlier identification of NCFBE patients with P. aeruginosa, as this may lead to fewer severe exacerbations, thereby resulting in a reduction in hospitalizations and healthcare costs.

A retrospective study to assess clinical characteristics and time to initiation of open-triple therapy among patients with chronic obstructive pulmonary disease, newly established on long-acting mono- or combination therapy

INTRODUCTION

An incremental approach using open-triple therapy may improve outcomes in patients with chronic obstructive pulmonary disease (COPD). However, there is little sufficient, real-world evidence available identifying time to open-triple initiation.

METHODS

This retrospective study of patients with COPD, newly initiated on long-acting muscarinic antagonist (LAMA) monotherapy or inhaled corticosteroid/long-acting β₂-agonist (ICS/LABA) combination therapy, assessed baseline demographics, clinical characteristics, and exacerbations during 12 months prior to first LAMA or ICS/LABA use. Time to initiation of open-triple therapy was assessed for 12 months post-index date. Post hoc analyses were performed to assess the subsets of patients with pulmonary-function test (PFT) information and patients with and without comorbid asthma.

RESULTS

Demographics and clinical characteristics were similar between cohorts in the pre-specified and post hoc analyses. In total, 283 (19.3%) and 160 (10.9%) patients had moderate and severe exacerbations at baseline, respectively, in the LAMA cohort, compared with 482 (21.3%) and 289 (12.8%) patients in the ICS/LABA cohort. Significantly more patients initiated open-triple therapy in the LAMA cohort compared with the ICS/LABA cohort (226 [15.4%] versus 174 [7.7%]; P<0.001); results were similar in the post hoc analyses. Mean (standard deviation) time to open-triple therapy was 79.8 (89.0) days in the LAMA cohort and 122.9 (105.4) days in the ICS/LABA cohort (P<0.001). This trend was also observed in the post hoc analyses, though the difference between cohorts was nonsignificant in the subset of patients with PFT information.

DISCUSSION

In this population, patients with COPD are more likely to initiate open-triple therapy following LAMA therapy, compared with ICS/LABA therapy. Further research is required to identify factors associated with the need for treatment augmentation among patients with COPD.

The epidemiology, diagnosis, and cost of dyspepsia and Helicobacter pylori gastritis: a case-control analysis in the Southwestern United States

BACKGROUND

Dyspepsia is among the most common complaints evaluated by gastroenterologists, but there are few studies examining its current epidemiology, evaluation, and costs. We examined these issues in a large managed care system in the Southwestern United States.

METHODS

We conducted a retrospective case-control analysis of adults with incident dyspepsia or a Helicobacter pylori-related condition in years 2006 through 2010 using utilization data. Medical record abstraction of 400 cases was conducted to obtain additional clinical information.

RESULTS

A total of 6989 cases met all inclusion and exclusion criteria. Women had a substantially higher risk of dyspepsia than men (14 per 1000 per year vs 10 per 1000; p < .001), and the incidence of dyspepsia increased with age such that persons in their seventh decade had almost twice the risk of those aged 18-29. Hispanic persons had a significantly higher risk of dyspepsia and positive H. pylori testing. Dyspepsia cases had a higher prevalence of other chronic comorbidities than their matched controls. Dyspepsia patients had healthcare costs 54% higher than controls even before the diagnosis was made, and costs in the initial diagnostic period were $483 greater per person, but subsequent costs were not greatly affected. Among those aged 55 and younger, the "test and treat" approach was used in 53% and another 18% had an initial esophagogastroduodenoscopy, as compared to 47 and 27%, respectively, among those over the age of 55.

CONCLUSIONS

Women and older adults have a higher incidence of dyspepsia than previously appreciated, and Hispanics in this region also have a higher risk. Current guidelines for dyspepsia evaluation are only loosely followed.

Changes in COPD demographics and costs over 20 years

OBJECTIVE

Chronic obstructive pulmonary disease (COPD) is now the third leading cause of death in the US and responsible for significant healthcare resource use. The purpose of this study was to examine the changes in COPD costs over 20 years and assess total direct cost trends over the last 10.

METHODS

A cross-sectional study of a population-based survey (2007 Medical Expenditure Panel Survey compared to the 1987 National Medical Expenditures Panel Survey) of respondents aged 40 and older with COPD (ICD-9-CM codes 491.xx, 492.xx, or 496.xx) was assessed for demographic and healthcare services use characteristics and compared to reported statistics from 1987. Ten-year trends in total direct medical costs from 1997-2007 are presented.

RESULTS

In 2007, there were 416 survey respondents with COPD compared to 228 in 1987. In 1987, women were only 39% of the COPD sample, while in 2007 they made up 58% of the sample. Mean cost per COPD patient was $16,135 (2007 dollars) in 2007, which was up from $11,807 (2007 dollars) in 1987 or a 37% increase. The proportional cost of emergency department visits (183%) and prescription drugs (170%) from 1987-2007 was high compared to other healthcare services. However, the mean cost of a hospitalization was the highest actual increase ($2289). Ten-year trends show a similar gradual increase.

CONCLUSIONS

The prevalence of COPD among females as well as the mean cost per COPD patient has risen sharply over the last 20 years. Cost-shifting from acute services to preventive services may allow US payers and healthcare providers to improve care and better manage costs for patients with COPD. More attention on prevention, diagnosis, and management needs to be directed to women at risk of COPD.

Comparative effectiveness of budesonide/formoterol and fluticasone/salmeterol for COPD management

OBJECTIVE

To compare the effectiveness of budesonide/formoterol fumarate dihydrate (BFC) and fluticasone propionate/salmeterol (FSC), two combination inhaled corticosteroid/long-acting beta-agonist (ICS/LABA) products approved for the treatment of chronic obstructive pulmonary disease (COPD) in the US with respect to cost, therapy adherence, and related healthcare utilization. The effectiveness of these two treatments has not previously been compared in a US COPD population.

METHODS

A retrospective cohort study assessed COPD-related outcomes using administrative claims data among ICS/LABA-naïve patients. Patients initiating BFC were propensity matched to FSC patients. Cost and effectiveness were measured as total healthcare expenditures, exacerbation events (hospitalizations, emergency department visits, or outpatient visits associated with oral corticosteroid or antibiotic prescription fills), and treatment medication adherence. Differences in COPD symptom control were assessed via proxy measure through claims for rescue medications and outpatient encounters.

RESULTS

Of the 6770 patients (3385 BFC and 3385 FSC), fewer BFC patients had claims for short-acting beta agonists (SABA) (34.7% vs 39.5%; p<0.001) and ipratropium (7.8% vs 9.8%, p<0.005) than FSC patients, but no substantial differences were seen in other clinical outcomes including tiotropium or nebulized SABA claims, COPD-related outpatient visits, or exacerbation events. There were no significant differences in total COPD-related medical costs in the 6-month period after initiation of combination therapy.

LIMITATIONS

This was a retrospective observational study using claims data and accuracy of COPD diagnoses could not be verified, nor was information available on severity of disease. The results and conclusions of this study are limited to the population observed and the operational definitions of the study variables.

CONCLUSIONS

For most outcomes of interest, BFC and FSC showed comparable real-world effectiveness.

Adherence to controller therapy for chronic obstructive pulmonary disease: a review

OBJECTIVE

While several studies have examined adherence to controller medications for the treatment of COPD, few systematic reviews have taken the translational step to identifying important and necessary areas for further research. The objective of this study was to review data on the outcomes of adherence to various controller therapies in patients with COPD in an effort to help prescribers understand adherence properties for each therapy.

RESEARCH DESIGN AND METHODS

This is a systematic review of studies investigating adherence to an array of controller pharmaceutical regimens. The studies were obtained from PubMed during 2008 and 2009 using the following key words: chronic obstructive pulmonary disease, COPD, adherence, controller medication, and persistence. Only articles encompassing adherence or persistence data to controller medications and published after 1990 were utilized.

RESULTS

After the search results were filtered for only the articles that pertained to adherence or persistence measurements in COPD, 35 articles remained; and finally, discounting those articles not published in English, articles which did not compare treatments for COPD, as well as those which were review articles, ten applicable articles remained. Each of these found low levels of medication adherence and/or persistence among patients receiving medications for COPD. Patients receiving fluticasone/salmeterol (FSC) and tiotropium (TIO) for treatment showed the highest adherence among all controller medications. Patients who were married, older, and white were more likely to adhere to their medications.

CONCLUSION

Characteristics of the medication used (i.e. dosing schedule, formulation, etc.) as well as patient characteristics affect the adherence/persistence to medications for the treatment of COPD. Further patient education is necessary in order to effectively improve disease management and patient outcomes in COPD. There is a need for future research and educational efforts to improve adherence in COPD and more clearly identify specific behavioral and treatment characteristics associated with specific COPD medications that can facilitate adherence.

Pneumonia among COPD patients using inhaled corticosteroids and long-acting bronchodilators

AIM

To assess the risk of pneumonia among COPD patients using salmeterol/fluticasone propionate combination inhalers (SFC), inhaled corticosteroids (ICS), or long-acting beta-agonists (LABA), alone or in combination, compared to those using only short-acting bronchodilators (SABD).

METHOD

The study population comprised 5245 individuals using inhaled treatment for COPD, identified from the databases of three large regional managed care organisations from different parts of the USA. Longitudinally-collected administrative data were obtained on their clinical histories and treatments. Nested case-control methods were used to calculate adjusted odds ratios (OR) for the risk of pneumonia while on therapy.

RESULTS

2154 patients had at least one diagnosed case of pneumonia between 1st September 2001 and 31st August 2003. Relative to SABD, the only treatment associated with a non-significant increased risk of pneumonia was ICS used alone (OR=1.29; 95%CI: 0.96-1.73; p=0.09). Users of LABA alone (OR=0.92; 95%CI: 0.69-1.22) or SFC (OR=1.03; 95%CI: 0.74-1.42) had no increased risk for pneumonia relative to SABD. Advanced age and severity of lung disease were strongly associated with increased risk for pneumonia.

CONCLUSION

Treatment with ICS or an ICS/LABA combination inhaler was not associated with a significantly increased risk of developing pneumonia.

The cost of chronic obstructive pulmonary disease and its effects on managed care

Chronic obstructive pulmonary disease (COPD) designates respiratory disorders characterized by airway obstruction that is not fully reversible. An estimated 10 million adult Americans have COPD, and the prevalence is rising. Direct and indirect costs of managing COPD exceed dollars 32 billion annually, and this health care burden has provoked vigorous efforts by major public health organizations to evaluate and improve quality of care for COPD. The authors review the substantial effects of COPD on managed care and discuss evidence-based strategies for its effective management.

Obtaining evidence for use by healthcare payers on the success of chronic obstructive pulmonary disease management

Healthcare payers make decisions on funding for treatments for diseases, such as chronic obstructive pulmonary disease (COPD), on a population level, so require evidence of treatment success in appropriate populations, using usual routine care as the comparison for alternative management approaches. Such health outcomes evidence can be obtained from a number of sources. The 'gold standard' method for obtaining evidence of treatment success is usually taken as the randomized controlled prospective clinical trial. Yet the value of such studies in providing evidence for decision-makers can be questioned due to the restricted entry criteria limiting the ability to generalize to real life populations, narrow focus on individual parameters, use of placebo for comparison rather than usual therapy and unrealistic intense monitoring of patients. Evidence obtained from retrospective and observational studies can supplement that from randomized clinical trials, providing that care is taken to guard against bias and confounders. However, very large numbers of patients must be investigated if small differences between drugs and treatment approaches are to be detected. Administrative databases from healthcare systems provide an opportunity to obtain observational data on large numbers of patients. Such databases have shown that high healthcare costs in patients with COPD are associated with co-morbid conditions and current smoking status. Analysis of an administrative database has also shown that elderly patients with COPD who received inhaled corticosteroids within 90 days of discharge from hospital had 24% fewer repeat hospitalizations for COPD and were 29% less likely to die during the 1-year follow-up period. In conclusion, there are a number of sources of meaningful evidence of the health outcomes arising from different therapeutic approaches that should be of value to healthcare payers making decisions on resource allocation.

The health impact of undiagnosed airflow obstruction in a national sample of United States adults

To determine the health and functional impact of undiagnosed airflow obstruction for subjects in the general population, we used data obtained as part of the Third National Health and Nutrition Examination Survey (NHANES III). Categories of diagnosed and undiagnosed airflow obstruction were defined using questionnaire responses and spirometric results. Health and functional impact of airflow obstruction was assessed from responses to questions about general health status, walking 1/4 mile, lifting or carrying something as heavy as 10 lb, or needing help with personal care. Undiagnosed airflow obstruction (12.0%) was more common than doctor-diagnosed chronic obstructive pulmonary disease (COPD) (3.1%) or asthma (2.7%). Although undiagnosed airflow obstruction was usually very mild, approximately 5% of the entire sample had an FEV(1) less than 75% predicted. After adjusting for smoking, obesity, and comorbid conditions, the risk of impaired health and functional status with undiagnosed airflow obstruction was independently associated with severity of FEV(1) impairment. For males and females, ever smoking was strongly associated with all types of airflow obstruction, diagnosed or not. However, among females with airflow obstruction, 12.2% to 35.2% never smoked. Undiagnosed airflow obstruction is common in the general population of the United States and is associated with impaired health and functional status.

KEYWORDS

airflow obstruction; spirometry; health impact; screening

Esophageal rupture after regional anesthesia: report of two cases

Esophageal perforation after anesthesia is rare. It is usually secondary to esophageal instrumentation. Only one case of barogenic rupture after regional anesthesia has been reported. We report two additional cases and present possible mechanisms for this unusual entity. Neither patient had anatomic abnormalities by history or preoperative endoscopy. However, both patients and the previously reported patient had esophageal dysmotility resulting from advanced age, alcoholism, intraoperative medications, and preexisting disease. Each patient experienced at least one episode of emesis with subsequent perforation of the distal one third of the esophagus. The previously reported patient died; both of our patients underwent successful surgical repair and are alive 2 years later. Intraoperative or postoperative emesis in patients with esophageal dysmotility appears to be the principal factor causing esophageal rupture after regional anesthesia. Prevention of nausea and vomiting and recognition of this high-risk population may minimize this complication in the future.

Primary mediastinal malignancies: findings in 219 patients

The purpose of this study was to determine the demographics, histology, methods of treatment, and survival in primary mediastinal malignancies. We did a retrospective review of the statewide New Mexico Tumor Registry for all malignant tumors treated between January 1, 1973 and December 31, 1995. Benign tumors and cysts of the mediastinum were excluded. Two hundred nineteen patients were identified from a total of 110,284 patients with primary malignancies: 55% of tumors were lymphomas, 16% malignant germ cell tumors, 14% malignant thymomas, 5% sarcomas, 3% malignant neurogenic tumors, and 7% other tumors. There were significant differences in gender between histologies (P < 0.001). Ninety-four percent of germ cell tumors occurred in males, 66% of neurogenic tumors were in females; other tumors occurred in males in 58% of cases. There were also significant differences in ages by histology (P < 0.001). Neurogenic tumors were most common in the first decade, lymphomas and germ cell tumors in the second to fourth decades, and lymphomas and thymomas in patients in their fifth decades and beyond. Stage at presentation (P = 0.001) and treatment (P < 0.001) also differed significantly between histologic groups. Five-year survival was 54% for lymphomas, 51% for malignant germ cell tumors, 49% for malignant thymomas, 33% for sarcomas, 56% for neurogenic tumors, and 51% overall. These survival rates were not statistically different (P > 0.50). Lymphomas, malignant germ cell tumors, and thymomas were the most frequently encountered malignant primary mediastinal neoplasms in this contemporary series of patients. Demographics, stage at presentation, and treatment modality varied significantly by histology. Despite these differences, overall five-year survival was not statistically different.