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:

• long-acting beta₂-agonists
• arformoterol
• nebulized therapy
• COPD
• Medicare
• treatment patterns

Acknowledgments

We thank Vaidy Ganapathy, PhD, formerly an employee of Sunovion Pharmaceuticals Inc., and Cynthia Ingrao, RN, BSN, DNP, from Advance Health Solutions, for their support with various stages of study implementation. We also extend our appreciation to Gulshan Sharma, MD, MPH, for his insightful support with analytic plan development and results interpretation. An earlier version of this paper with interim findings was presented at the CHEST 2017 Annual Meeting as a podium presentation. The presentation’s abstract was published in “Poster Abstracts” in CHEST: https://journal.chestnet.org/article/S0012-3692(17)32324-3/abstract. DOI: https://doi.org/10.1016/j.chest.2017.08.806.

Author contributions

BRC, MN, ZX, SCR, CD, and TPG all made substantial contributions to the conception, design, and/or interpretation of data. ZX and TPG were responsible for data acquisition and data analysis. All authors contributed to data analysis, drafting and revising the article, gave final approval of the version to be published, and agree to be accountable for all aspects of the work.

Disclosure

BRC received consultation remuneration as a member of the Medical Advisory Board at Advance Health Solutions, LLC. He has also been an expert pulmonologist consultant for Glaxo Smith Kline, Boehringer-Ingelheim, Astra Zeneca, Novartis, and Pulmonix. He reports personal fees from Boehringer INgelheim, Glaxo Smith Kline, Astra Zeneca, Novartis, and Chiesi, outside the submitted work. MN and SCR are employed by Advance Health Solutions, LLC which received funding from Sunovion Pharmaceuticals Inc. to oversee this study. ZX and TPG are employed by the University of California San Diego which received a grant from Advance Health Solutions, LLC to conduct this study. CD is employed by Sunovion Pharmaceuticals Inc. The authors report no other conflicts of interest in this work.