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Observational Study
. 2013 Oct 23;8(10):e75221.
doi: 10.1371/journal.pone.0075221. eCollection 2013.

Overtreatment of COPD with inhaled corticosteroids--implications for safety and costs: cross-sectional observational study

Patrick White  1 , Hannah Thornton, Hilary Pinnock, Sofia Georgopoulou, Helen P Booth
Affiliations
Observational Study

Overtreatment of COPD with inhaled corticosteroids--implications for safety and costs: cross-sectional observational study

Patrick White et al. PLoS One. .

Abstract

Introduction: Combined inhaled long-acting beta-agonists and corticosteroids (LABA+ICS) are costly. They are recommended in severe or very severe chronic obstructive pulmonary disease (COPD). They should not be prescribed in mild or moderate disease. In COPD ICS are associated with side-effects including risk of pneumonia. We quantified appropriateness of prescribing and examined the risks and costs associated with overuse.

Methods: Data were extracted from the electronic and paper records of 41 London general practices (population 310,775) including spirometry, medications and exacerbations. We classified severity, assessed appropriateness of prescribing using the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines for 2009, and performed a sensitivity analysis using the broader recommendations of the 2011 revision.

Results: 3537 patients had a diagnosis of COPD. Spirometry was recorded for 2458(69%). 709(29%) did not meet GOLD criteria. 1749(49%) with confirmed COPD were analysed: 8.6% under-treated, 38% over-treated. Over-prescription of ICS in GOLD stage I or II (n=403, 38%) and in GOLD III or IV without exacerbations (n=231, 33.6%) was common. An estimated 12 cases (95%CI 7-19) annually of serious pneumonia were likely among 897 inappropriately treated. 535 cases of overtreatment involved LABA+ICS with a mean per patient cost of £553.56/year (€650.03). Using the broader indications for ICS in the 2011 revised GOLD guideline 25% were still classified as over-treated. The estimated risk of 15 cases of pneumonia (95%CI 8-22) in 1074 patients currently receiving ICS would rise by 20% to 18 (95%CI 9.8-26.7) in 1305 patients prescribed ICS if all with GOLD grade 3 and 4 received LABA+ICS.

Conclusion: Over-prescription of ICS in confirmed COPD was widespread with considerable potential for harm. In COPD where treatment is often escalated in the hope of easing the burden of disease clinicians should consider both the risks and benefits of treatment and the costs where the benefits are unproven.

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Conflict of interest statement

Competing Interests: Dr. Patrick White has received speaker fees from AstraZeneca, British Thoracic Society, European Respiratory Society, Primary Care Respiratory Society, Elsevier, National Council on Palliative Care (UK), International Primary Care Respiratory Group, COPD7, BMJ Masterclass, Primary Care 2009 conference, he has received hospitality at respiratory conferences from Boehringer Ingelheim and Pfizer, and he has received payment from the Wellcome Foundation to review research applications. Dr Hilary Pinnock has participated in advisory groups for Chiesi and Napp, she is involved with the EU/IMI funded PROactive project which is supported by a consortium of pharma companies, she has received speaker fees from AstraZeneca / Boehringer Ingelheim / Pfizer, and Napp, and she has received hospitality at respiratory conferences from GSK and Napp. This does not alter the authors' adherence to all the PLOS ONE policies on sharing data and materials.

Figures

Figure 1
Figure 1. Identification of subjects and categorization by diagnosis and severity (GOLD stage) in 41 practices.
Figure 2
Figure 2. Proportion of patients with spirometric confirmation of diagnosis of COPD in each treatment classification by GOLD stage.
See this image and copyright information in PMC

References

    1. Miravitlles M, de la Roza C, Naberan K, Lamban M, Gobartt E et al. (2007) Use of spirometry and patterns of prescribing in COPD in primary care. Respir_Med 101: 1753-1760. PubMed: 17448651. - PubMed
    1. Jones RC, Dickson-Spillmann M, Mather MJ, Marks D, Shackell BS (2008) Accuracy of diagnostic registers and management of chronic obstructive pulmonary disease: the Devon primary care audit. Respir Res 9: 62. doi: 10.1186/1465-9921-9-62. PubMed: 18710575. - DOI - PMC - PubMed
    1. Jebrak G, Initiatives B (2010) COPD routine management in France: are guidelines used in clinical practice?. Rev Mal Respir 27: 11-18. doi: 10.1016/S0761-8425(10)70003-6. PubMed: 20146947. - DOI - PubMed
    1. Strong M, South G, Carlisle R (2009) The UK Quality and Outcomes Framework pay-for-performance scheme and spirometry: rewarding quality or just quantity? A cross-sectional study in Rotherham, UK. BMC Health Serv_Res 9: 108. doi: 10.1186/1472-6963-9-108. PubMed: 19558719. - DOI - PMC - PubMed
    1. White P, Wong W, Fleming T, Gray B (2007) Primary care spirometry: test quality and the feasibility and usefulness of specialist reporting. Br_J_Gen_Pract 57: 701-705. PubMed: 17761057. - PMC - PubMed

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