Medication Discontinuation in Adults With COPD Discharged From the Hospital: A Population-Based Cohort Study.

BACKGROUND: Patients admitted to the hospital with COPD are commonly managed with inhaled short-acting bronchodilators, sometimes in lieu of the long-acting bronchodilators they take as outpatients. If held on admission, these long-acting inhalers should be re-initiated upon discharge; however, health-care transitions sometimes result in unintentional discontinuation. RESEARCH QUESTION: What is the risk of unintentional discontinuation of long-acting muscarinic antagonist (LAMA) and long-acting beta-agonist and inhaled corticosteroid (LABA-ICS) combination medications following hospital discharge in older adults with COPD? STUDY DESIGN AND METHODS: A retrospective cohort study was conducted by using health administrative data from 2004 to 2016 from Ontario, Canada. Adults with COPD aged ≥ 66 years who had filled prescriptions for a LAMA or LABA-ICS continuously for ≥ 1 year were included. Log-binomial regression models were used to determine risk of medication discontinuation following hospitalization in each medication cohort. RESULTS: Of the 27,613 hospitalization discharges included in this study, medications were discontinued 1,466 times. Among 78,953 patients with COPD continuously taking a LAMA or LABA-ICS, those hospitalized had a higher risk of having medications being discontinued than those who remained in the community (adjusted risk ratios of 1.50 [95% CI, 1.34-1.67; P < .001] and 1.62 [95% CI, 1.39, 1.90; P < .001] for LAMA and LABA-ICS, respectively). Crude rates of discontinuation for people taking LAMAs were 5.2% in the hospitalization group and 3.3% in the community group; for people taking LABA-ICS, these rates were 5.5% in the hospitalization group and 3.1% in the community group. INTERPRETATION: In an observational study of highly compliant patients with COPD, hospitalization was associated with an increased risk of long-acting inhaler discontinuation. These Results suggest a likely larger discontinuation problem among less adherent patients and should be confirmed and quantified in a prospective cohort of patients with COPD and average compliance. Quality improvement efforts should focus on safe transitions and patient medication reconciliation following discharge.

Longitudinal associations between number of cigarettes per day and depressive symptoms in adult smokers with type 2 diabetes: A path analysis approach.

OBJECTIVE: Three theoretical models describe the direction of the association between depressive symptoms and cigarettes per day (CPD) in smokers: 1) CPD predicts subsequent depressive symptoms, 2) depressive symptoms predict CPD, and 3) there is a bidirectional relation between CPD and depressive symptoms. The objective of the study was to compare the fit of these three theoretical models to data from a community-based sample of adults with type 2 diabetes (T2D) who smoke cigarettes. METHODS: Data were from adults with T2D who participated in the Evaluation of Diabetes Treatment Study. At baseline, 296 participants reported being a current smoker and were included in the analyses. Measures of CPD and depressive symptoms were collected annually over four years. Path models corresponding to the three directionality hypotheses were estimated. Model fit was compared, and the best fitting model was selected on the basis of Akaike's Information Criterion (AIC). RESULTS: The path model depicting a unidirectional association from CPD to subsequent depressive symptoms had the lowest AIC value (7110.94) and was thus identified as the best fitting model. Although some paths within the model did not meet conventional levels of statistical significance, in general, more CPD predicted higher levels of depressive symptoms at subsequent follow-up points. CONCLUSION: Amongst smokers with T2D, a primary smoking model, in which smoking precedes depressive symptoms, may best explain the longitudinal association between CPD and depressive symptoms. These findings further justify the need for early smoking cessation in diabetes care.

Patterns of health care use related to respiratory conditions in early life: A birth cohort study with linked administrative data.

OBJECTIVES: To identify distinctive patterns of respiratory-related health services use (HSU) between birth and 3 years of age, and to examine associated symptom and risk profiles. METHODS: This study included 729 mother and child pairs enrolled in the Toronto site of the Canadian Healthy Infant Longitudinal Development study in 2009-2012; they were linked to Ontario health administrative databases (2009-2016). A model-based cluster analysis was performed to identify distinct groups of children who followed a similar pattern of respiratory-related HSU between birth and 3 years of age, regarding hospitalization, emergency department (ED) and physician office visits for respiratory conditions and total health care costs (2016 Canadian dollars). RESULTS: The majority (estimated cluster weight = 0.905) showed a pattern of low and stable respiratory care use (low HSU) while the remainder (weight = 0.095) showed a pattern of high use (high HSU). From 0 to 3 years of age, the low- and high-HSU groups differed in mean trajectories of total health care costs ($783 per 6 months decreased to $114, vs $1796 to $177, respectively). Compared to low-HSU, the high-HSU group was associated with a constant risk of hospitalizations, early high ED utilization and physician visits for respiratory problems. The two groups differed significantly in the timing of wheezing (late onset in low-HSU vs early in high-HSU) and future total costs (stable vs increased). CONCLUSIONS: One in ten children had high respiratory care use in early life. Such information can help identify high-risk young children in a large population, monitor their long-term health, and inform resource allocation.