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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
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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.
Retrospective Case-Series Analysis

A retrospective case-series analysis was performed after all patients had been reassessed. Patients were included if they were 18 years or older, were originally treated with an ICS/LABA inhaler and a LAMA inhaler and switched to a LAMA/LABA inhaler and an ICS inhaler, had a diagnosis of COPD in their electronic health record (EHR), had baseline CAT scores, and had follow-up CAT scores within 1 to 6 months of regimen change. Patients were excluded if they had an exacerbation within 6 weeks of reassessment, as this may have led to unreliable CAT scores during their recovery.7

Patient EHRs were reviewed for patient demographic information, insurance coverage, baseline and follow-up inhaler regimens, patient-reported CAT scores, and patient-reported number of moderate and severe exacerbations. Days between the original prescription date of the new regimen and the date of follow-up were also included in data collection.

The primary outcome was mean difference in CAT scores before and after the regimen change. The literature reports that a 2-point change in CAT score is considered clinically significant.8-10 Microsoft Excel 2016 (Microsoft Corporation; Redmond, Washington) was used to collect and store data, and Minitab 17 (Minitab Inc; State College, Pennsylvania) was used to perform statistical analysis. Data were visually inspected for normal distribution and then analyzed using a paired t test with an α value of 0.05.

The University at Buffalo institutional review board approved this study, and the need for patient consent was waived. All patient data were deidentified and randomly assigned a patient number prior to data analysis.


Of the 118 patients identified by the insurer for the original quality improvement program, just 19 met the inclusion criteria. Baseline patient characteristics from the quality improvement project and the research study are presented in Table 1. Of the 118 initially eligible patients using triple therapy, 44 agreed to make a change, 11 were stepped down, and 63 had no change. Patient enrollment and outcomes are depicted in eAppendix D. A total of 22 patients failed to meet the inclusion criteria (no baseline CAT score [n = 1], physician denied change [n = 7], patient changed regimen [n = 7], changed insurers [n = 1], deceased [n = 2], unable to contact [n = 4]). Additionally, 2 patients were hospitalized for pneumonia and 1 for an upper respiratory infection; they were therefore excluded.

Patient CAT scores and inhaler regimens are presented in Table 2. The mean (SD) CAT score at baseline was 15.53 (5.36) and after the change in inhalers was 14.68 (6.98). The primary outcome of mean difference in CAT score was –0.84 (95% CI, –3.57 to 1.89; P = .525). The mean (SD) time between initial contact and reassessment was 136 (40) days.


In this study, patients who were changed from triple therapy with an ICS/LABA inhaler and a LAMA inhaler to a LAMA/LABA inhaler and an ICS inhaler showed a small improvement in symptoms as seen by the decreased CAT score (–0.84), although this difference was not statistically or clinically significant. The lack of change in CAT scores after changing COPD triple therapy supports the use of any combination of inhalers, particularly a regimen that is less expensive. Current guidelines do not support using 1 specific agent over others, so the uneven distribution of inhalers due to local prescribing practices would not limit the applicability of this study.1

With the increased prevalence of accountable care organizations, alternative payment models, and the Merit-based Incentive Payment System, healthcare providers need to provide quality care without incurring extra costs.11,12 Identifying high-cost drugs and presenting less expensive options will be important for value-based contracting as fee-for-service is de-emphasized. Additionally, for conditions like COPD in which adherence to expensive drugs is essential for preventing complications, it is important to find regimens that patients can afford without compromising efficacy. Our pharmacy team is in a good position within the PCMH for identifying these trends and working with providers to address these issues, as seen with this quality improvement project.

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