A recent retrospective, noninterventional cohort study shed light on the pharmacologic treatment patterns and outcomes of 238,158 patients newly diagnosed with chronic obstructive pulmonary disease in the United States.
The study, published in BMC Pulmonary Medicine, used de-identified data from the Inovalon Insights' database, following patients' journeys over a 4-year period from January 1, 2015, to December 31, 2021. The mean age of the cohort was 63.8 years, with 52.9% of patients being female, 40.5% residing in the South, and 46.2% insured by Medicaid.
Moderate exacerbations were defined as ambulatory visits with a chronic obstructive pulmonary disease (COPD) diagnosis plus a prescription for oral corticosteroids or antibiotics within 7 days; severe exacerbations were defined as inpatient admissions or emergency department visits with a primary COPD diagnosis or related conditions.
During the 4-year follow-up, 32.9% of patients had at least one moderate or severe exacerbation (25.8% moderate and 13.8% severe). Of all exacerbations, 69.1% were moderate and 30.9% were severe.
Exacerbation rates peaked in the first year after COPD diagnosis (0.15/person-years: moderate, 0.07/person-years: severe) and then remained relatively stable. The study found that 86.2% of patients were untreated at diagnosis, and 63.8% remained untreated at the end of follow-up. "Untreated" patients were defined as those who received short-acting rescue medication only or no COPD medications.
Among the 13.8% who received maintenance therapy within 30 days of diagnosis, 44.7% and 23.9% had moderate and severe exacerbations, respectively, compared to 14.5% and 7.2% of those who remained untreated.
The most common initial maintenance therapy was a long-acting beta-agonist plus an inhaled corticosteroid (LABA/ICS), prescribed to 62% of patients at COPD diagnosis and 58% to 64% throughout follow-up. Long-acting muscarinic antagonist (LAMA) monotherapy was used by 30.3% of patients at diagnosis and 18.6% to 25.5% during follow-up, while LAMA/LABA dual therapy use increased from 6.4% at diagnosis to 15.9% at year 4. Triple therapy (LABA/LAMA/ICS) was rarely used initially—by only 0.01% of patients at diagnosis—but rose to 5% by year 4.
In the overall cohort, short-acting beta-agonists were the most frequently prescribed treatment, used by 38.4% at year 1 and remaining the most-used therapy throughout follow-up. LABA/ICS (used by 18.3%–21.4%) and ICS alone (used by 13.2%–16.4%) were the next most common.
A subgroup analysis compared exacerbation rates between patients diagnosed in inpatient versus outpatient settings, finding higher rates among those diagnosed as inpatients.
The study included data from the COVID-19 pandemic period, which may have impacted health-care utilization. Sensitivity analyses revealed similar patterns but higher magnitudes of utilization in prepandemic years.
Some limitations of the study included potential selection bias, as patients had to seek care in a health-care setting to be included, and the inability to measure COPD severity due to lack of clinical data.
The study authors concluded, "Most patients with COPD were not treated at initial diagnosis and remained untreated during follow-up. Our data highlight a lack of adherence to recommendations for clinical practice."
A statement of competing interests can be found in the study.