Guideline Alignment and Medication Concordance in COPD

BackgroundProvider adherence to clinical treatment guidelines in COPD is low. However, for patients to receive guideline-aligned care, providers not only must prescribe guideline-aligned care, but also must communicate that regimen successfully to patients to ensure medication concordance. The rate of medication concordance between patients and providers and its impact on clinical management is unknown in COPD.Research QuestionTo examine rates of guideline alignment and medication concordance and to identify patient-level factors that place patients at risk for these types of poor disease management outcomes.Study Design and MethodsThis study was a secondary data analysis of the Medication Adherence Research in COPD study (2017-2023). Participants were categorized into 2017 Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage. Medication regimens were classified as aligned or nonaligned with 2017 GOLD guidelines. Nonaligned regimens were stratified further into overuse and underuse categories. Medication concordance between provider-reported and participant-reported regimens was determined. Factors associated with guideline alignment and medication concordance were evaluated using logistic regression.ResultsOf 191 participants, 51% of provider-reported regimens were guideline aligned, with 86% of nonaligned regimens reflecting overuse with an inhaled corticosteroid (ICS). Thirty-eight percent of participants reported different regimens than their providers, of which > 80% reflected participants not reporting medications their providers reported prescribing. Participants did not report long-acting muscarinic antagonists and long-acting beta-agonists at similar rates as ICSs. Greater symptom burden and absence of a pulmonologist on the care team were associated with both guideline misalignment and medication discordance. Cognitive impairment and Black race additionally were associated with medication discordance.InterpretationGuideline misalignment and medication discordance were common and were driven by overuse of ICSs and unreported medications, respectively. The patient-level factors associated with medication discordance highlight the importance of improving patient-provider communication to improve clinical management in COPD. Provider adherence to clinical treatment guidelines in COPD is low. However, for patients to receive guideline-aligned care, providers not only must prescribe guideline-aligned care, but also must communicate that regimen successfully to patients to ensure medication concordance. The rate of medication concordance between patients and providers and its impact on clinical management is unknown in COPD. To examine rates of guideline alignment and medication concordance and to identify patient-level factors that place patients at risk for these types of poor disease management outcomes. This study was a secondary data analysis of the Medication Adherence Research in COPD study (2017-2023). Participants were categorized into 2017 Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage. Medication regimens were classified as aligned or nonaligned with 2017 GOLD guidelines. Nonaligned regimens were stratified further into overuse and underuse categories. Medication concordance between provider-reported and participant-reported regimens was determined. Factors associated with guideline alignment and medication concordance were evaluated using logistic regression. Of 191 participants, 51% of provider-reported regimens were guideline aligned, with 86% of nonaligned regimens reflecting overuse with an inhaled corticosteroid (ICS). Thirty-eight percent of participants reported different regimens than their providers, of which > 80% reflected participants not reporting medications their providers reported prescribing. Participants did not report long-acting muscarinic antagonists and long-acting beta-agonists at similar rates as ICSs. Greater symptom burden and absence of a pulmonologist on the care team were associated with both guideline misalignment and medication discordance. Cognitive impairment and Black race additionally were associated with medication discordance. Guideline misalignment and medication discordance were common and were driven by overuse of ICSs and unreported medications, respectively. The patient-level factors associated with medication discordance highlight the importance of improving patient-provider communication to improve clinical management in COPD. Despite widespread acceptance of clinical treatment guidelines for COPD, provider adherence to these guidelines remains low.1Ghosh S. Anderson W.H. Putcha N. et al.Alignment of inhaled chronic obstructive pulmonary disease therapies with published strategies. Analysis of the Global Initiative for Chronic Obstructive Lung Disease recommendations in SPIROMICS.Ann Am Thorac Soc. 2019; 16: 200-208Crossref PubMed Scopus (28) Google Scholar The most commonly cited treatment guidelines are published by the Global Initiative for Chronic Obstructive Lung Disease (GOLD), a project established in 1997 to create evidence-based guidelines for the prevention, diagnosis, and management of COPD. These guidelines offer specific recommendations for the selection of pharmacologic therapy in COPD based on categories of disease severity.2Vogelmeier C.F. Criner G.J. Martinez F.J. et al.Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 report. GOLD executive summary.Am J Respir Crit Care Med. 2017; 195: 557-582Crossref PubMed Scopus (2255) Google Scholar Although providers report awareness of these guidelines and general agreement with their recommendations,3Perez X. Wisnivesky J.P. Lurslurchachai L. Kleinman L.C. Kronish I.M. Barriers to adherence to COPD guidelines among primary care providers.Respir Med. 2012; 106: 374-381Abstract Full Text Full Text PDF PubMed Scopus (122) Google Scholar prior studies have described rates of alignment between prescribing patterns and treatment guidelines of approximately 50%.1Ghosh S. Anderson W.H. Putcha N. et al.Alignment of inhaled chronic obstructive pulmonary disease therapies with published strategies. Analysis of the Global Initiative for Chronic Obstructive Lung Disease recommendations in SPIROMICS.Ann Am Thorac Soc. 2019; 16: 200-208Crossref PubMed Scopus (28) Google Scholar,4López-Campos J.L. Abad Arranz M. Calero-Acuña C. et al.Guideline adherence in outpatient clinics for chronic obstructive pulmonary disease: results from a clinical audit.PLoS One. 2016; 11 (1-13): e0151896Crossref PubMed Scopus (18) Google Scholar, 5Sharif R. Cuevas C.R. Wang Y. Arora M. Sharma G. Guideline adherence in management of stable chronic obstructive pulmonary disease.Respir Med. 2013; 107: 1046-1052Abstract Full Text Full Text PDF PubMed Google Scholar, 6Sehl J. O’Doherty J. O’Connor R. O’Sullivan B. O’Regan A. Adherence to COPD management guidelines in general practice? A review of the literature.Ir J Med Sci. 2018; 187: 403-407Crossref PubMed Scopus (39) Google Scholar Patients not receiving guideline-aligned care may be at increased risk of poor health outcomes and may be exposed to unnecessary harm. Undertreatment, which for patients with disease severity worse than GOLD stage A involves absence of a long-acting muscarinic antagonist (LAMA), long-acting beta-agonist (LABA), or both, has been associated with worse symptom control7Appleton S. Jones T. Poole P. et al.Ipratropium bromide versus long-acting beta-2 agonists for stable chronic obstructive pulmonary disease.Cochrane Database Syst Rev. 2006; 3 (CD006101, 1-47)Google Scholar and, for patients with a history of exacerbations, carries an additional risk of future exacerbations.8Decramer M.L. Chapman K.R. Dahl R. et al.Once-daily indacaterol versus tiotropium for patients with severe chronic obstructive pulmonary disease (INVIGORATE): a randomised, blinded, parallel-group study.Lancet Respir Med. 2013; 1: 524-533Abstract Full Text Full Text PDF PubMed Scopus (214) Google Scholar,9Anthonisen N.R. Connett J.E. Enright P.L. Manfreda J. Hospitalizations and mortality in the Lung Health Study.Am J Respir Crit Care Med. 2002; 166: 333-339Crossref PubMed Scopus (468) Google Scholar Overtreatment, which usually involves prescription of an inhaled corticosteroid (ICS) for patients with GOLD stage B disease, has been associated with an increased risk of pneumonia as well as poor glucose control and risk of fractures.10Crim C. Calverley P.M. Anderson J.A. et al.Pneumonia risk in COPD patients receiving inhaled corticosteroids alone or in combination: TORCH study results.Eur Respir J. 2009; 34: 641-647Crossref PubMed Scopus (362) Google Scholar, 11Loke Y.K. Cavallazzi R. Singh S. Risk of fractures with inhaled corticosteroids in COPD: systematic review and meta-analysis of randomised controlled trials and observational studies.Thorax. 2011; 66: 699-708Crossref PubMed Scopus (216) Google Scholar, 12Slatore C.G. Bryson C.L. Au D.H. The association of inhaled corticosteroid use with serum glucose concentration in a large cohort.Am J Med. 2009; 122: 472-478Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar, 13Spece L.J. Feemster L.C. Aligning prescribing practices with chronic obstructive pulmonary disease guidelines: a Sisyphean struggle?.Ann Am Thorac Soc. 2019; 16: 187-188Crossref PubMed Scopus (0) Google Scholar In addition, overtreatment may complicate patients’ medication regimens unnecessarily and may worsen issues of medication adherence, which for patients with COPD has been shown to be poor.9Anthonisen N.R. Connett J.E. Enright P.L. Manfreda J. Hospitalizations and mortality in the Lung Health Study.Am J Respir Crit Care Med. 2002; 166: 333-339Crossref PubMed Scopus (468) Google Scholar Therefore, improving alignment with guidelines has important implications for improving health outcomes. For patients to receive guideline-aligned care, providers not only must prescribe guideline-aligned treatment, but also must communicate with patients in a way that ensures medication concordance, or agreement between patients and providers about the medication regimen. Although little is known about rates of patient-provider medication concordance in COPD, medication concordance in other chronic diseases has been shown to be poor.14Riekert K.A. Butz A.M. Eggleston P.A. Huss K. Winkelstein M. Rand C.S. Caregiver-physician medication concordance and undertreatment of asthma among inner-city children.Pediatrics. 2003; 111: e214-e220Crossref PubMed Google Scholar, 15Butz A. Sellers M.D. Land C. Walker J. Tsoukleris M. Bollinger M.E. Factors affecting primary care provider and caregiver concordance for pediatric asthma medications.J Asthma. 2009; 46: 308-313Crossref PubMed Scopus (4) Google Scholar, 16Redmond P. Grimes T.C. McDonnell R. Boland F. Hughes C. Fahey T. Impact of medication reconciliation for improving transitions of care.Cochrane Database Syst Rev. 2018; 8 (CD010791, 1-125)PubMed Google Scholar Moreover, patients with COPD face barriers to medication concordance beyond their peers because of disproportionately high rates of cognitive impairment, depression and anxiety, and comorbid disease.17Schneider C. Jick S.S. Bothner U. Meier C.R. COPD and the risk of depression.Chest. 2010; 137: 341-347Abstract Full Text Full Text PDF PubMed Scopus (150) Google Scholar, 18Fan V.S. Meek P.M. Anxiety, depression, and cognitive impairment in patients with chronic respiratory disease.Clin Chest Med. 2014; 35: 399-409Abstract Full Text Full Text PDF PubMed Google Scholar, 19Smith M.C. Wrobel J.P. Epidemiology and clinical impact of major comorbidities in patients with COPD.Int J Chron Obstruct Pulmon Dis. 2014; 9: 871-888Crossref PubMed Scopus (260) Google Scholar In addition, patients with COPD have been shown to have unique health beliefs about medications that may impair their ability to engage with their treatment plan.20Krauskopf K. Federman A.D. Kale M.S. et al.Chronic obstructive pulmonary disease illness and medication beliefs are associated with medication adherence.COPD. 2015; 12: 151-164Crossref PubMed Scopus (69) Google Scholar Understanding rates of medication concordance in COPD and the association of patient-level factors with medication concordance may help to identify patients who need additional support to understand the medication regimen. This study used an existing cohort of patients with COPD to examine rates at which providers prescribe GOLD guideline-aligned treatment, rates of patient-provider medication concordance, and the interplay between guideline alignment and medication concordance. We further examined how patient-level factors are associated with both guideline alignment and medication concordance to identify patients at higher risk of these types of poor disease management. Medication Adherence Research in COPD Patients (MARC) was a multicenter cohort study conducted between Johns Hopkins Medicine (Baltimore, Maryland) and ChristianaCare (Wilmington, Delaware) from 2017 through 2023 of participants aged ≥ 40 years who received a physician diagnosis of COPD and who were prescribed a long-term daily medication for COPD. Participants were recruited from among former clinical research participants and patient volunteers. All participants provided written informed consent. Institutional review boards at Johns Hopkins Medicine (Identifier: IRB00091482) and ChristianaCare (Identifier: IRB00000479) approved the protocol. The analytical cohort for this study is limited to MARC participants with GOLD stage B, C, or D disease according to 2017 GOLD categorization to ensure that all participants an for a long-term daily the participants on clinical exacerbations, prescribed medication and prescribing were as respiratory the use of or both or health care use in the prior using pulmonary in with and et of and J Respir Crit Care Med. 2019; PubMed Scopus Google Scholar the Research R. R. Jones J.A. of the Research as a of in patients with chronic obstructive pulmonary PubMed Google Scholar COPD G. P. W.H. N. and of the COPD Respir J. 2009; 34: PubMed Scopus Google Scholar Cognitive N. and of the cognitive for who are 2010; Google Scholar and which of beliefs in the of medications and about their R. Chapman R. N. A. 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