J. Karafilidis

Hospital readmissions following initiation of nebulized arformoterol tartrate or nebulized short-acting beta-agonists among inpatients treated for COPD

Background Inpatient admissions for chronic obstructive pulmonary disease (COPD) represent a significant economic burden, accounting for over half of direct medical costs. Reducing 30-day readmissions could save health care resources while improving patient care. Recently, the Patient Protection and Affordable Care Act authorized reduced Medicare payments to hospitals with excess readmissions for acute myocardial infarction, heart failure, and pneumonia. Starting in October 2014, hospitals will also be penalized for excess COPD readmissions. This retrospective database study investigated whether use of arformoterol, a nebulized long-acting beta agonist, during an inpatient admission, had different 30-day all-cause readmission rates compared with treatment using nebulized short-acting beta agonists (SABAs, albuterol, or levalbuterol). Methods A US nationally representative hospital database was used to study adults aged ≥40 years, discharged between January, 2006 and March, 2010, and with a diagnosis of COPD. Patients receiving arformoterol on ≥80% of days following treatment initiation were compared with patients receiving a nebulized SABA during hospitalization. Arformoterol and nebulized SABA patients were matched (1:2) for age, sex, severity of inpatient admission, and primary/secondary COPD diagnosis. Logistic regression compared the odds of readmission while adjusting for age, sex, race, admission type, severity, primary/secondary diagnosis, other respiratory medication use, respiratory therapy use, oxygen use, hospital size, and teaching status. Results This retrospective study compared 812 arformoterol patients and 1,651 nebulized SABA patients who were discharged from their initial COPD hospital admission. An intensive care unit stay was more common among arformoterol patients (32.1% versus 18.4%, P<0.001), suggesting more severe symptoms during the initial admission. The observed readmission rate was significantly lower for arformoterol patients than for nebulized SABA patients (8.7% versus 11.9%, P=0.017), as were the adjusted odds of readmission (odds ratio 0.69, 95% confidence interval 0.51–0.92). Conclusion All-cause 30-day readmission rates were significantly lower for arformoterol patients than nebulized SABA patients, both before and after adjusting for patient and hospital characteristics.

Risk of all-cause hospitalization in COPD patients initiating long-acting or short-acting beta agonist therapy

Abstract Objective: This retrospective claims study investigated the rates of all-cause hospitalization among chronic obstructive pulmonary disease (COPD) patients initiating treatment with short-acting beta agonists (SABA) or long-acting beta agonists (LABA). Methods: Data from the 5% national sample of Medicare enrollees for 2006–2008 were used. Patients initiating COPD therapy were identified as those with no COPD therapy for ≥ 6-months prior to initiating SABA or LABA (administered via dry-powder inhalers, metered-dose inhalers, or nebulizer) treatment. All patients were continuously eligible for Medicare Parts A, B, and D for 18 months. Those enrolled in Medicare Advantage, who had asthma, or were < 65 years old were excluded. Differences in the rates of all-cause hospitalizations and time to all-cause hospitalization during the 6-month follow-up period were examined, while adjusting for demographics, clinical indicators, and health service use. Results: Among 3017 COPD patients who met the inclusion criteria, 883 (30%) were LABA users and 2134 (70%) were SABA users. Overall, 21% of patients (16% [144/883] of LABA and 23% [492/2134] of SABA) had a hospitalization during the follow-up period. Mean time to hospitalization was 86 days for LABA vs 64 days for SABA patients (p < 0.05). The adjusted hazard ratio for hospitalization in a Cox proportional hazards model was 0.74 (95% CI = 0.62–0.90) for patients treated with LABA vs. SABA. Limitations: The analysis was adjusted for multiple background characteristics, but important measures of severity in COPD, such as measures of lung functioning, were not available and may have differed between patients treated with LABA or SABA. Conclusions: The results of this analysis indicate COPD patients initiating LABA treatment had a longer time to all-cause hospitalization and a 26% lower risk of hospitalization during the 6-months follow-up period compared to those initiating SABA therapy.

Comparison of Efficacy and Safety Outcomes in Randomized Trials ofLong-Acting and Short-Acting ÃÂ2-Agonists for Chronic ObstructivePulmonary Disease: A Review

Limited information is available comparing the efficacy and safety of Short-Acting β2-agonists (SABAs) versus long-acting β2-agonists (LABAs) for maintenance therapy in Chronic Obstructive Pulmonary Disease (COPD). The objective of this research was to conduct a systematic literature review and evaluate COPD-related outcomes in a meta-analysis. The literature review identified randomized clinical trials of LABAs and SABAs as maintenance therapy in adults with stable COPD. PubMed/Medline, Embase, and the Cochrane Library were searched for reports published between January 1, 1990 and July 16, 2010. Only studies of at least 2 weeks in duration were included. Few studies directly comparing LABAs and SABAs were expected; therefore, studies with placebo or ipratropium were included for a potential indirect-comparison. A total of 938 studies were identified with 62 meeting all inclusion criteria. Only one study directly compared outcomes for LABA versus SABA. This study reported significantly better airflow and greater reduction in symptoms for the LABA treatment. Twelve studies evaluated a SABA with a shared common comparator, but indirect metaanalysis was not tenable due to different outcome variables. The efficacy and safety of LABAs and SABAs in patients with COPD has been demonstrated, but only LABAs have supporting data for maintenance treatment. In usual clinical care, SABAs appear to be used in place of LABAs for long-term therapy, despite the lack of any empirical support. This review supports the current evidence-based guidelines that recommend LABAs for maintenance therapy in adults with stable COPD and reserves SABAs for use as rescue medications.