Economic Assessment of Initial Maintenance Therapy for Chronic Obstructive Pulmonary Disease

Department of Health Policy and Administration, University of North Carolina at Chapel Hill, USA.
The American journal of managed care (Impact Factor: 2.26). 08/2008; 14(7):438-48.
Source: PubMed


To compare the effects of initial maintenance therapy with fluticasone 250 microgram plus salmeterol 50 microgram in a single inhaler versus other inhaled medications on exacerbation risks and treatment costs among chronic obstructive pulmonary disease (COPD) patients.
A retrospective observational analysis was conducted by using medical/pharmacy claims from a large managed care database between January 2000 and February 2004. Patients age 40 years or older with a primary diagnosis of COPD (International Classification of Diseases, Ninth Revision, Clinical Modification code 490, 491, 492, or 496), at least 18 months of continuous eligibility, and an index prescription for fluticasone/salmeterol combination, salmeterol alone, inhaled corticosteroid alone, ipratropium/albuterol combination, or ipratropium alone (reference) were identified.
Time to first COPD-related hospitalization or emergency department (ED) visit was estimated by using Cox proportional hazard models. All-cause and COPD-related treatment costs were estimated by using generalized linear models with a gamma distribution and log link. Multivariable regressions were used, controlling for age, sex, comorbidities, COPD subtype, preindex medications, and hospitalizations and ED visits.
Initial maintenance therapy with fluticasone/salmeterol combination was associated with a 31% to 56% lower risk of hospitalization or ED visit compared with ipratropium alone, adjusting for baseline characteristics and preindex resource utilization. Fluticasone/salmeterol combination therapy was related to lower medical costs, higher pharmacy costs, and almost similar total costs in all populations studied.
Fluticasone/salmeterol combination therapy was considered to be cost-effective compared with ipratropium alone because it achieved better clinical outcomes with similar or lower treatment costs.

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    • "While the efficacy and tolerability of triple therapy have been evaluated in clinical trials, the effect on COPD outcomes of triple therapy relative to TIO alone has not been assessed in the real-world setting (ie, outside the confines of a controlled clinical trial). Furthermore, although research on the pharmacoeconomic impact of FSC and ipratropium has been done [18], the potential impact of triple therapy relative to TIO alone on healthcare costs has not been assessed. The study reported herein was conducted to compare the risks of COPD exacerbations and COPD-related healthcare costs between patients initiating TIO alone and patients initiating triple therapy with FSC added to TIO. "
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    ABSTRACT: This retrospective cohort study compared the risks of exacerbations and COPD-related healthcare costs between patients with chronic obstructive pulmonary disease (COPD) initiating tiotropium (TIO) alone and patients initiating triple therapy with fluticasone-salmeterol combination (FSC) added to TIO. Managed-care enrollees who had an index event of ≥ 1 pharmacy claim for TIO during the study period (January 1, 2003-April 30, 2008) and met other eligibility criteria were categorized into one of two cohorts depending on their medication use. Patients in the TIO+FSC cohort had combination therapy with TIO and FSC, defined as having an FSC claim on the same date as the TIO claim. Patients in the TIO cohort had no such FSC use. The risks of COPD exacerbations and healthcare costs were compared between cohorts during 1 year of follow-up. The sample comprised 3333 patients (n = 852 TIO+FSC cohort, n = 2481 TIO cohort). Triple therapy with FSC added to TIO compared with TIO monotherapy was associated with significant reductions in the adjusted risks of moderate exacerbation (hazard ratio 0.772; 95% confidence interval [CI] 0.641, 0.930) and any exacerbation (hazard ratio 0.763; 95% CI 0.646, 0.949) and a nonsignificant reduction in COPD-related adjusted monthly medical costs. Triple therapy with FSC added to TIO compared with TIO monotherapy was associated with significant reductions in the adjusted risks of moderate exacerbation and any exacerbation over a follow-up period of up to 1 year. These improvements were gained with triple therapy at roughly equal cost of that of TIO alone.
    Respiratory research 02/2012; 13(1):15. DOI:10.1186/1465-9921-13-15 · 3.09 Impact Factor
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    • "Finally, in a retrospective claims analysis involving 1051 adults ≥65 years with COPD, FSC compared with ipratropium was associated with a 45% reduction in the risk of COPD-related hospitalization or emergency department visit, and lower COPD-related medical costs.22 In several of these studies,16,21,22 FSC-associated reductions in medical costs appeared to more than offset the increase in pharmacy costs such that total costs (medical plus pharmacy) were lower with FSC (although total costs were not reported in one study);21 however, pharmacy costs were higher with FSC than with the short-acting anticholinergic bronchodilator. Across studies comparing FSC with short- and long-acting anticholinergic bronchodilators in patients selected without regard to presence of comorbid depression, FSC was associated with significantly lower risk of COPD-related events and, generally, lower total medical costs. "
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    ABSTRACT: Chronic obstructive pulmonary disease (COPD) is frequently associated with comorbid depression and anxiety. Managing COPD symptoms and exacerbations through use of appropriate and adequate pharmacotherapy in this population may result in better COPD-related outcomes. This retrospective, observational study used administrative claims of patients aged 40 years and older with COPD and comorbid depression/anxiety identified from January 1, 2004 through June 30, 2008. Patients were assigned to fluticasone propionate/salmeterol 250/50 mcg combination (FSC) or anticholinergics (AC) based on their first (index) prescription. The risks of COPD exacerbations and healthcare utilization and costs were compared between cohorts during 1 year of follow-up. The adjusted risk of a COPD-related exacerbation during the 1-year follow-up period was 30% higher in the AC cohort (n = 2923) relative to the FSC cohort (n = 1078) (odds ratio [OR]: 1.30, 95% confidence interval [CI]: 1.08-1.56) after controlling for baseline differences in covariates. The risks of COPD-related hospitalizations and emergency department visits were 56% and 65% higher, respectively, in the AC cohort compared with the FSC cohort. The average number of COPD-related hospitalizations during the follow-up period was 46% higher for the AC cohort compared with the FSC cohort (incidence rate ratio [IRR]: 1.46, 95% CI: 1.01-2.09, P = 0.041). The savings from lower COPD-related medical costs ($692 vs $1042, P < 0.050) kept the COPD-related total costs during the follow-up period comparable to those in the AC cohort ($1659 vs $1677, P > 0.050) although the pharmacy costs were higher in the FSC cohort. FSC compared with AC was associated with more favorable COPD-related outcomes and lower COPD-related utilization and medical costs among patients with COPD and comorbid anxiety/depression.
    International Journal of COPD 01/2012; 7:11-9. DOI:10.2147/COPD.S27846 · 3.14 Impact Factor
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    • "Among managed care enrollees, those prescribed ICS plus LABA had a 47% lower risk for a COPD hospitalization (HR 0.533, 95% CI, 0.328 to 0.865) and a 36% lower risk for any respiratory admission compared to ipratropium therapy (HR 0.643; 95% CI, 0.512 to 0.808).75 Newly diagnosed COPD patients receiving initial maintenance therapy with FSC had a 32% lower risk for hospitalization/ED visit during the first 6 months of therapy compared with patients receiving ipratropium therapy (HR 0.685, 95% CI, 0.620 to 0.757), and a lower risk than patients receiving either fluticasone propionate or salmeterol.76 Two US studies, one in a Texas Medicaid population and one in a cohort of Medicare-eligible health plan members, reported 27% and 45% reductions in risk, respectively, for a COPD-related hospitalization or ED visit with FSC compared to ipratropium.73,77 "
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    ABSTRACT: Exacerbations contribute significantly to the morbidity of COPD, leading to an accelerated decline in lung function, reduced functional status, reduced health status and quality of life, poorer prognosis and increased mortality. Prevention of exacerbations is thus an important goal of COPD management. In patients with COPD, treatment with a combination of the inhaled corticosteroid fluticasone propionate (250 microg) and the long-acting beta(2)-agonist salmeterol (50 microg) in a single inhaler (250/50 microg) is an effective therapy option that has been shown to reduce the frequency of exacerbations, to improve lung function, dyspnea and health status, and to be relatively cost-effective as a COPD maintenance therapy. Importantly, results of various studies suggest that fluticasone propionate and salmeterol have synergistic effects when administered together that improve their efficacy in controlling symptoms and reducing exacerbations. The present non-systematic review summarizes the role of fluticasone propionate/salmeterol combination therapy in the prevention of exacerbations of COPD and its related effects on lung function, survival, health status, and healthcare costs.
    International Journal of COPD 06/2010; 5:165-78. DOI:10.2147/COPD.S4159 · 3.14 Impact Factor
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