Medication management patterns among Medicare beneficiaries with chronic obstructive pulmonary disease who initiate nebulized arformoterol treatment

Abstract

Purpose: Global evidence-based treatment strategies for chronic obstructive pulmonary disease (COPD) recommend using long-acting bronchodilators (LABDs) as maintenance therapy. However, COPD patients are often undertreated. We examined COPD treatment patterns among Medicare beneficiaries who initiated arformoterol tartrate, a nebulized long-acting beta₂ agonist (LABA), and identified the predictors of initiation. Methods: Using a 100% sample of Medicare administrative data, we identified beneficiaries with a COPD diagnosis (ICD-9 490-492.xx, 494.xx, 496.xx) between 2010 and 2014 who had ≥1 year of continuous enrollment in Parts A, B, and D, and ≥2 COPD-related outpatient visits within 30 days or ≥1 hospitalization(s). After applying inclusion/exclusion criteria, three cohorts were identified: (1) study group beneficiaries who received nebulized arformoterol (n=11,886), (2) a subset of the study group with no LABD use 90 days prior to initiating arformoterol (n=5,542), and (3) control group beneficiaries with no nebulized LABA use (n=220,429). Logistic regression was used to evaluate predictors of arformoterol initiation. Odds ratios (ORs), 95% confidence intervals (CIs), and p values were computed. Results: Among arformoterol users, 47% (n=5,542) had received no LABDs 90 days prior to initiating arformoterol. These beneficiaries were being treated with a nebulized (50%) or inhaled (37%) short-acting bronchodilator or a systemic corticosteroid (46%), and many received antibiotics (37%). Compared to controls, beneficiaries who initiated arformoterol were significantly more likely to have had an exacerbation, a COPD-related hospitalization, and a pulmonologist or respiratory therapist visit prior to initiation (all p<0.05). Beneficiaries with moderate/severe psychiatric comorbidity or dual-eligible status were significantly less likely to initiate arformoterol, as compared to controls (all p<0.05). Conclusion: Medicare beneficiaries who initiated nebulized arformoterol therapy had more exacerbations and hospitalizations than controls 90 days prior to initiation. Findings revealed inadequate use of maintenance medications, suggesting a lack of compliance with evidence-based treatment guidelines.

Keywords: COPD; Medicare; arformoterol; long-acting beta2-agonists; nebulized therapy; treatment patterns.

Figure 1

Flow chart depicting selection of sample and study cohorts. ^aFull coverage and COPD diagnosis <1 year prior to first nebulized LABA claim. Excluded deaths before first nebulized LABA claims. Abbreviations: COPD, chronic obstructive pulmonary disease; ESRD, end-stage renal disease; LABA, long-acting beta₂ agonist; LABD, long-acting bronchodilators; SNF, skilled nursing facility.

Figure 2

Number of long-acting and short-acting bronchodilators filled by Medicare beneficiaries 90 days before initiating nebulized arformoterol (N=11,886). With the exception of beneficiaries taking 0 medication, no other categories are mutually exclusive (ie, categories refer to taking at least 1, 2, or 3 therapeutic agents).

Figure 3

Medication use by Medicare beneficiaries 90 days before and after initiating nebulized arformoterol (N=11,886). Percentages are not mutually exclusive. Abbreviations: CS, corticosteroid; LABA, long-acting beta₂ agonist; ICS, inhaled corticosteroid; LAMA, long-acting muscarinic antagonist; SABD, short-acting bronchodilator.

Figure 4

COPD medication patterns 90 days before initiating nebulized arformoterol among Medicare beneficiaries who received no long-acting bronchodilators (N=5,542). Percentages are not mutually exclusive. Abbreviations: CS, corticosteroid; ICS, inhaled corticosteroid; SABD, short-acting bronchodilator.