Health care utilization history, GOLD guidelines, and respiratory medication prescriptions in patients with COPD

Abstract

Background: The relationship between prior health care utilization and respiratory medication prescriptions in an unselected population of patients with COPD is not known.

Methods: We determined the prescribed respiratory medications and respiratory and nonrespiratory health care encounters in 523 Veterans with COPD at the Cincinnati Veterans Affairs Medical Center between 2000 and 2005. Prescribed treatments were compared with the GOLD guidelines and each patient was classified as receiving less medications than recommended in the guidelines (<G), medications according to the guidelines (=G), or more medications than recommended (>G).

Results: Respiratory medications were <G for 54%, =G in 33%, and >G for 14% of the patients studied. For GOLD stages 1 and 2, <G patients had the fewest and >G patients the most prior respiratory encounters during a 12 month period (0.31 +/- 0.073 (0.21, 0.47), 0.75 +/- 0.5 (0.37, 1.5), 1.1 +/- 0.27 (0.74, 1.6) visits/person/year, <G, =G, >G, respectively, mean + standard error of mean (SEM) (95% confidence limits) 2 degrees of freedom (df) ANOVA P < 0.001 for prescription effect). For GOLD stages 3 and 4, <G was associated with significantly fewer prior respiratory visits than was =G (0.78 +/- 0.11 (0.6, 1.0) and 2.4 +/- 0.47 (1.9, 3.1) visits/person/year, respectively, P < 0.001). There were no differences in nonrespiratory health care visits for GOLD stages 1 and 2 by prescription level (3.1 +/- 0.24 (2.6, 3.5), 3.1 +/- 0.46 (2.1, 4.6) and 4.1 +/- 0.55 (3.3, 5.1) visits/person/year, <G, =G, >G respectively, 2 df ANOVA P = 0.096) or for GOLD stages 3 and 4 (3.6 +/- 0.25 (3.2, 4.1) and 4.0 +/- 0.44 (3.3, 4.9) visits/person/year, <G and =G, respectively, P = 0.36).

Conclusions: Respiratory medications prescribed for an unselected population with a broad range of COPD severity complied poorly with the GOLD pharmacologic treatment guidelines but correlated with the number of prior respiratory health care visits.

Keywords: COPD; GOLD guidelines; health care; prescription; respiratory visits.

Figure 1

Flow diagram for inclusion and exclusion of study patients. Note: The diagnosis of COPD was defined by ICD-9 codes, 491.XX (Chronic Bronchitis), 492.XX (Emphysema) and 496.XX (Chronic Obstructive Lung Disease).

Figure 2

Distribution of health care encounters over 12 and 60 month intervals. Notes: Results are mean ± SEM. Panel A shows hospital, ED, outpatient, and total respiratory visits. Panel B shows hospital, ED, outpatient, and total nonrespiratory visits. Abbreviations: Hospital, hospitalizations; ED, emergency department visits; Outpatient, outpatient health care encounters; All, total health care encounters.

Figure 3

Health care encounters during the 12 month period (A, B) and the 60 month period (C, D) according to modified GOLD stage. Notes: Results are mean ± SEM (95% confidence interval). Panel A shows hospital, ED, outpatient, and total respiratory visits. Patients with advanced COPD had more respiratory health care visits compared with individuals with a clinical diagnosis of COPD (0.36 ± 0.067 (0.24, 0.54), 0.29 ± 0.15 (0.11, 0.77), 0.58 ± 0.11 (0.42, 0.80), 1.0 ± 0.23 (0.77, 1.3), and 1.4 ± 0.19 (1.1, 1.7) visits/person/year over the 12 month period for clinical COPD (former GOLD stage 0) and modified GOLD stages 1, 2, 3, and 4 respectively, 4 df ANOVA P < 0.001). Panel B shows hospital, ED, outpatient, and total nonrespiratory visits. The frequency of nonrespiratory health care visits was the same in all groups regardless of modified GOLD stage (3.8 ± 0.24 (3.4, 4.3), 3.2 ± 0.39 (2.4, 4.3), 3.3 ± 0.24 (2.9, 3.8), 3.6 ± 0.46 (3.1, 4.1), and 3.8 ± 0.31 (3.3, 4.3) visits/person/year for clinical COPD and modified GOLD stages 1, 2, 3, and 4 respectively, 4 df ANOVA P = 0.51). Panel C shows the number of office, ED, and hospital respiratory visits increasing with each modified GOLD stage from 0.34 ± 0.032 visits/person/year in patients with a clinical diagnosis of COPD to 1.1 ± 0.13 visits/person/year for those individuals in modified GOLD stage 4 (4df ANOVA comparing all groups, P < 0.001). Panel D shows similar numbers of hospital, ED, office, and total nonrespiratory visits in each modified GOLD stage, 4df ANOVA comparing all groups P = 0.45).

Figure 4

Frequency of yearly health care respiratory health care encounters per person during the 12 and 60 month periods.