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The American Journal of Managed Care April 2019
Time to Fecal Immunochemical Test Completion for Colorectal Cancer
Cameron B. Haas, MPH; Amanda I. Phipps, PhD; Anjum Hajat, PhD; Jessica Chubak, PhD; and Karen J. Wernli, PhD
From the Editorial Board: Kavita K. Patel, MD, MS
Kavita K. Patel, MD, MS
Comment on Generalizability of GLP-1 RA CVOTs in US T2D Population
Maureen J. Lage, PhD
Authors’ Reply to “Comment on Generalizability of GLP-1 RA CVOTs in US T2D Population”
Eric T. Wittbrodt, PharmD, MPH; James M. Eudicone, MS, MBA; Kelly F. Bell, PharmD, MSPhr; Devin M. Enhoffer, PharmD; Keith Latham, PharmD; and Jennifer B. Green, MD
Deprescribing in the Context of Multiple Providers: Understanding Patient Preferences
Amy Linsky, MD, MSc; Mark Meterko, PhD; Barbara G. Bokhour, PhD; Kelly Stolzmann, MS; and Steven R. Simon, MD, MPH
The Health and Well-being of an ACO Population
Thomas E. Kottke, MD, MSPH; Jason M. Gallagher, MBA; Marcia Lowry, MS; Sachin Rauri, MS; Juliana O. Tillema, MPA; Jeanette Y. Ziegenfuss, PhD; Nicolaas P. Pronk, PhD, MA; and Susan M. Knudson, MA
Currently Reading
Effect of Changing COPD Triple-Therapy Inhaler Combinations on COPD Symptoms
Nick Ladziak, PharmD, BCACP, CDE; and Nicole Paolini Albanese, PharmD, BCACP, CDE
Do Health Systems Respond to the Quality of Their Competitors?
Daniel J. Crespin, PhD; Jon B. Christianson, PhD; Jeffrey S. McCullough, PhD; and Michael D. Finch, PhD
Impact of Clinical Training on Recruiting Graduating Health Professionals
Sheri A. Keitz, MD, PhD; David C. Aron, MD; Judy L. Brannen, MD; John M. Byrne, DO; Grant W. Cannon, MD; Christopher T. Clarke, PhD; Stuart C. Gilman, MD; Debbie L. Hettler, OD, MPH; Catherine P. Kaminetzky, MD, MPH; Robert A. Zeiss, PhD; David S. Bernett, BA; Annie B. Wicker, BS; and T. Michael Kashner, PhD, JD
Does Care Consultation Affect Use of VHA Versus Non-VHA Care?
Robert O. Morgan, PhD; Shweta Pathak, PhD, MPH; David M. Bass, PhD; Katherine S. Judge, PhD; Nancy L. Wilson, MSW; Catherine McCarthy; Jung Hyun Kim, PhD, MPH; and Mark E. Kunik, MD, MPH
Continuity of Outpatient Care and Avoidable Hospitalization: A Systematic Review
Yu-Hsiang Kao, PhD; Wei-Ting Lin, PhD; Wan-Hsuan Chen, MPH; Shiao-Chi Wu, PhD; and Tung-Sung Tseng, DrPH

Effect of Changing COPD Triple-Therapy Inhaler Combinations on COPD Symptoms

Nick Ladziak, PharmD, BCACP, CDE; and Nicole Paolini Albanese, PharmD, BCACP, CDE
Changing patients from an inhaled corticosteroid (ICS)/long-acting β agonist (LABA) inhaler and long-acting muscarinic agonist (LAMA) inhaler to a LAMA/LABA inhaler and a separate ICS inhaler did not appear to affect patient-reported chronic obstructive pulmonary disease (COPD) symptom scores.

Objectives: To determine if symptoms changed after changing chronic obstructive pulmonary disease (COPD) triple-therapy inhalers to a less expensive regimen.

Study Design: Retrospective observational case-series analysis.

Methods: A quality improvement program was instituted to reduce drug costs associated with COPD inhalers between fall 2016 and spring 2017. Patients identified as taking an inhaled corticosteroid (ICS)/long-acting β agonist (LABA) inhaler and a long-acting muscarinic agonist (LAMA) inhaler were changed to a LAMA/LABA inhaler and an ICS inhaler. Symptoms were assessed at baseline and subsequent follow-up using the COPD Assessment Test (CAT), with lower scores representing better symptom control. Then, a retrospective observational case-series analysis of 118 patient charts was completed. The primary outcome was mean difference in CAT score. Data were analyzed using a paired t test with an α value of 0.05.

Results: Of 118 patients included in the quality improvement program, 19 met the inclusion and exclusion criteria. The mean (SD) CAT score prior to the change was 15.53 (5.36), and the mean (SD) CAT score after the change was 14.68 (6.98). Symptom scores improved after the change, with an average difference in postchange and prechange CAT scores of –0.84, although this difference was not statistically significant (95% CI, –3.57 to 1.89; P = .525).

Conclusions: Based on the results of this observational review, changing COPD triple-therapy inhalers did not result in a significant change in patient-reported symptom scores. Patients may use triple-therapy inhalers that are most affordable without a significant change in symptom control.

Am J Manag Care. 2019;25(4):201-204
Takeaway Points

A quality improvement program was implemented to change patients with chronic obstructive pulmonary disease (COPD) to a less expensive combination of inhalers. This retrospective study examined changes in patient-reported symptom scores after changing to a less expensive COPD triple-therapy inhaler regimen.
  • Newly updated COPD guidelines offer recommendations on which agents to use based on patient presentation but do not recommend specific inhaler combinations.
  • Prescription inhaler costs are high and can present significant barriers to maintaining COPD symptom control at a reasonable cost to the healthcare system.
  • This study provides real-world data to support the use of the least expensive regimen without compromising patient care.
Chronic obstructive pulmonary disease (COPD) triple therapy consists of treatment with an inhaled corticosteroid (ICS), a long-acting β agonist (LABA), and a long-acting muscarinic antagonist (LAMA). Studies comparing COPD triple therapy regimens are scarce despite the 2017 Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines recommending triple therapy as a step-up option in patients with severe symptoms and a history of multiple exacerbations.1 Even with these guideline recommendations, there is no guidance for which specific inhalers to use.

Comparisons among triple-therapy combinations are limited. Recently, studies have shown the benefits of newer single-inhaler triple-therapy combinations compared with single or dual therapy.2,3 Withdrawal of an ICS from triple therapy does not significantly affect exacerbation rates, although a decrease in forced expiratory volume in 1 second (FEV1) was seen in one study.4 A recent meta-analysis showed that the addition of a LAMA to a LABA improved FEV1 compared with addition of an ICS to a LABA, but there was no significant impact on patient symptom scores.5 In a randomized controlled trial comparing exacerbation rates in patients with COPD, LAMA/LABA inhalers were significantly better at reducing the risk of any exacerbation compared with ICS/LABA inhalers.6

The pharmacy department at Buffalo Medical Group, PC, in Buffalo, New York, is part of a large patient-centered medical home (PCMH) and works closely with a local insurance company for various population health initiatives. According to the insurer’s 2016 formulary, single-agent ICS inhalers were in a lower tier than any other single or combination inhaler. According to 2015 gross cost data supplied by the insurer, the average cost per inhaler regimen consisting of an ICS/LABA inhaler ($298) and a LAMA inhaler ($310) was $608 compared with $493 for a LAMA/LABA inhaler ($300) and an ICS inhaler ($193), a difference of $115. These cost data led to the implementation of a quality improvement project to change patients from ICS/LABA and LAMA inhalers to LAMA/LABA and ICS inhalers. This study aims to describe the effect of these inhaler changes on symptom control and to review potential cost implications.


Quality Improvement Program

The insurer created a list of patients with concurrent prescription fill claims for an ICS/LABA inhaler and a LAMA inhaler in May 2016. Members of the pharmacy team (eg, pharmacists and fourth-year pharmacy students) contacted these patients to offer them a therapy change to a less expensive inhaler regimen, after first considering the COPD regimen and self-reported adherence, as well as exacerbation history and baseline symptoms. Adherence was assessed by asking patients how many doses of their maintenance inhalers they missed, on average, during 1 week. Exacerbation history included any use of acute steroids or antibiotics (moderate exacerbation) or hospitalization for respiratory issues (severe exacerbation) in the last 12 months. Patient-reported symptoms that occurred in the previous 2 weeks were evaluated using the COPD Assessment Test (CAT), which is a validated tool for assessing COPD symptoms, with lower scores representing better symptom control.7 Pulmonary function was not assessed because it is no longer used for classifying patients and determining therapy changes.1 The refined ABCD assessment tool from the GOLD guidelines (eAppendix A [eAppendices available at]) was used to classify patients.1

A therapeutic interchange was developed with the help of board-certified pulmonologists at the PCMH, as this information is not published. The therapeutic interchanges are available in eAppendices B and C.

Patients categorized in group A were offered step-down to a LAMA/LABA inhaler alone. Patients categorized in groups B, C, or D were offered a change to a LAMA/LABA inhaler and an ICS inhaler to reduce costs as they continued triple therapy. Patients who accepted the recommended change were counseled on proper inhaler technique if the new inhaler device did not match one in their current regimen. These patients were called again to ensure adherence and reassess symptoms. Multiple attempts were made to reach each patient if they did not respond to the initial call. Baseline and follow-up calls took place during fall 2016 and spring 2017.

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