Original researchAssociation of Chronic Obstructive Pulmonary Disease Maintenance Medication Adherence With All-Cause Hospitalization and Spending in a Medicare Population
Introduction
Chronic obstructive pulmonary disease (COPD) affects >1 in 15 (24 million) adults in the United States,1, 2 surpassing stroke as the third leading cause of death.3 COPD also affects 12% of elderly adults and disabled Medicare beneficiaries,4 and is frequently associated with comorbid conditions and increased disease severity.5, 6, 7 In 2007, the costs of COPD exceeded $42 billion, with $29.5 billion attributable to direct health care expenditures and $8 billion to mortality.8
Pharmacotherapy is a cornerstone of COPD management. Maintenance medications are effective in controlling symptoms, maintaining lung function, and preventing acute COPD exacerbations.1, 9 The regular use of bronchodilators, including long-acting β2-agonists (LABAs), anticholinergics, and methylxanthines, and LABAs and inhaled corticosteroids are effective in maintaining the health status of COPD patients.1, 9
Research suggested half of COPD patients failed to use any maintenance medications.10, 11 To maximize treatment outcomes, maintenance medications should be used on a long-term regular basis, and should not be discontinued.1 Although COPD medication adherence approached 80% in clinical trials,12 in clinical practice, observed adherence levels ranged from 10% to 60%13, 14, 15, 16, 17 and only half of patients continually used their prescribed medications for a year.10, 17, 18
Despite the clinical and economic implications associated with suboptimal COPD maintenance medication management, few studies examined the influence of medication adherence on hospitalization and costs. Although research suggested increased COPD maintenance medication use reduced hospitalization, emergency department visits, and associated costs,6, 11, 16, 19, 20, 21, 22 limitations remain and include: data on comparative cost-effectiveness of specific regimens (ie, head-to-head trials); need for studies on medication adherence; reliance on simulation techniques using hypothetical patients and imputed costs; and failure to target Medicare beneficiaries. Finally, despite growing recognition of the deleterious effects of medication discontinuation in individuals with cardiovascular disease,7 myocardial infarction,23, 24 and rheumatoid arthritis,25 discontinuation of medication remains unclear in COPD patients.
Using a nationally representative sample of Medicare beneficiaries, the objectives of this study were to: (1) estimate the prevalence of COPD maintenance medication continuity and adherence measured by proportion of days covered (PDC); and (2) examine the association of COPD maintenance medication continuity and adherence on hospitalization and Medicare spending.
Section snippets
Study Design and Data
This study was a retrospective cross-sectional study using a 5% random sample of Medicare claims records from the 2006 to 2007 Chronic Condition Warehouse (CCW). These 2 years were used to assess medication adherence among Medicare Part D enrollees during the first 2 years of their enrollment in the program. The CCW data included detailed administrative data for all Medicare Part A (inpatient), B (outpatient), and D (prescription drug) services.26 The first 6 months (January 1, 2006 to June 30,
Results
A sample of 33,816 beneficiaries with COPD who had at least 2 Part D prescription claims for COPD maintenance medications during the 18-month follow up was obtained. This sample was predominantly female (64.9%), white (87.3%), with a mean age of 71 years, and LIS eligible (63.7%) (Table I). Hypertension was the most common comorbid condition (69.9%), followed by ischemic heart disease (51.2%). Nearly 1 in 3 (31.8%) beneficiaries experienced a hospitalization at baseline (January 1, 2006 to June
Discussion
Results of this study demonstrated that increased measures of adherence to maintenance medications of proven benefit in COPD appeared to be significantly associated with reduced hospitalization rates and total Medicare spending. Both lack of interruption in drug dispensing and higher adherence were associated with better clinical outcomes. Increased adherence also resulted in significant decreases in total, Part A, and Part B Medicare spending. Although Part D prescription drug spending was
Conclusions
Findings from this study indicated that COPD maintenance medication use over an extended period was associated with better clinical and economic outcomes. Improving adherence might provide significant cost-savings—for the patient, who might incur copayments, and for the Medicare program. The results highlighted the need for interventions that improve the adherence of essential COPD maintenance medications to reduce exacerbations and associated costs.
Conflicts of Interests
This study was funded by GlaxoSmithKline. Dr. Dalal and Ms. Bryant-Comstock are employees of GlaxoSmithKline and own company stock. The remaining authors received financial support from GlaxoSmithKline to conduct the study. The authors have indicated that they have no other conflicts of interest regarding the content of this article.
Acknowledgments
This study was funded by GlaxoSmithKline. Dr. Simoni-Wastila was the guarantor of the article, taking responsibility for the integrity of the work as a whole, from inception to published article. Drs. Simoni-Wastila, Stuart, Zuckerman, and Dalal worked on the study concept and design. Dr. Simoni-Wastila acquired the data. Drs. Simoni-Wastila, Stuart, Zuckerman, Wei, Qian, Mr. Shaffer, and Dr. Dalal analyzed and interpreted the data. All of the authors drafted and revised the article. Drs. Wei,
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