Real-Time Use of SGLT2i Verified in Pre-dialysis: The RSVP Cross-sectional Study.

BACKGROUND: The use of sodium-glucose cotransporter 2 inhibitors (SGLT2i) in nephrology practice is increasingly becoming standard of care in patients with diabetes or those with proteinuria. OBJECTIVES: The primary outcome was to identify the proportion of pre-dialysis patients with chronic kidney disease (CKD) G3a, G3b, or G4 prescribed an SGLT2i and describe their characteristics. METHODS: This was a retrospective, multicentric, cross-sectional study of patients with CKD followed at 4 pre-dialysis clinics in the province of Quebec, Canada. We collected data of multiple covariates associated with prescribing SGLT2i in patients over 18 years of age with CKD G3a, G3b, or G4. We then performed a multivariate logistic regression to assess their associations. RESULTS: Of the 874 patients included, 22.7% were prescribed an SGLT2i. Factors most strongly associated included male sex (odds ratio [OR] = 4.88, 95% CI = 2.38-10.03), being prescribed metformin (OR = 4.30, 95% CI = 2.23-8.31), having type 2 diabetes (OR = 4.00, 95% CI = 1.86-8.62), or having an albumin-to-creatinine ratio greater than 300 mg/g (OR = 1.84, 95% CI = 1.08-3.14). The majority of patients (60.4%) had their SGLT2i initiated by the pre-dialysis clinic and the most frequent adverse event was an initial increase in serum creatinine 1 week after starting treatment (33.9%). CONCLUSION AND RELEVANCE: An increasing number of patients with CKD are being prescribed SGLT2i. Nonetheless, significant disparities in sex, severity of disease, and comorbidities remain. We suggest that specific strategies be put in place to promote prescribing of SGLT2i in women and other at-risk populations, in particular among nephrology teams, to improve patient care.

2023 Canadian Thoracic Society Guideline on Pharmacotherapy in Patients With Stable COPD.

Chronic obstructive pulmonary disease patient care must include confirming a diagnosis with postbronchodilator spirometry. Because of the clinical heterogeneity and the reality that airflow obstruction assessed by spirometry only partially reflects disease severity, a thorough clinical evaluation of the patient should include assessment of symptom burden and risk of exacerbations that permits the implementation of evidence-informed pharmacologic and nonpharmacologic interventions. This guideline provides recommendations from a comprehensive systematic review with a meta-analysis and expert-informed clinical remarks to optimize maintenance pharmacologic therapy for individuals with stable COPD, and a revised and practical treatment pathway based on new evidence since the 2019 update of the Canadian Thoracic Society (CTS) Guideline. The key clinical questions were developed using the Patients/Population (P), Intervention(s) (I), Comparison/Comparator (C), and Outcome (O) model for three questions that focuses on the outcomes of symptoms (dyspnea)/health status, acute exacerbations, and mortality. The evidence from this systematic review and meta-analysis leads to the recommendation that all symptomatic patients with spirometry-confirmed COPD should receive long-acting bronchodilator maintenance therapy. Those with moderate to severe dyspnea (modified Medical Research Council ≥ 2) and/or impaired health status (COPD Assessment Test ≥ 10) and a low risk of exacerbations should receive combination therapy with a long-acting muscarinic antagonist/long-acting ẞ2-agonist (LAMA/LABA). For those with a moderate/severe dyspnea and/or impaired health status and a high risk of exacerbations should be prescribed triple combination therapy (LAMA/LABA/inhaled corticosteroids) azithromycin, roflumilast or N-acetylcysteine is recommended for specific populations; a recommendation against the use of theophylline, maintenance systemic oral corticosteroids such as prednisone and inhaled corticosteroid monotherapy is made for all COPD patients.

Feasibility of implementing a web-based tool built from pharmacy claims data (e-MEDRESP) to monitor adherence to respiratory medications in primary care.

OBJECTIVE: e-MEDRESP is a novel web-based tool that provides easily interpretable information on patient adherence to asthma/chronic obstructive pulmonary disease (COPD) medications, using pharmacy claims data. This study investigated the feasibility of implementing e-MEDRESP in primary care. MATERIAL AND METHODS: In this 16-month prospective cohort study, e-MEDRESP was integrated into electronic medical records. Nineteen family physicians and 346 of their patients were enrolled. Counters embedded in the tool tracked physician use during the follow-up. Patient/physician satisfaction with e-MEDRESP was evaluated though telephone interviews and online questionnaires. The capacity of e-MEDRESP to improve adherence was explored using a pre-post analysis. RESULTS: Overall, 245 patients had at least one medical visit during follow-up. e-MEDRESP was consulted by 15 (79%) physicians for 85 (35%) patients during clinic visits. Seventy-three patients participated in telephone interviews; 84% reported discussing their medication use with their physician; 33% viewed their e-MEDRESP report and indicated that it was easy to interpret. The physicians reported that the tool facilitated their evaluation of their patients' medication adherence (mean ± standard deviation rating: 4.8 ± 0.7, on a 5-point Likert scale). Although the pre-post analysis did not reveal improved adherence in the overall cohort, adherence improved significantly in patients whose adherence level was <80% and who were prescribed inhaled corticosteroids (26.9% [95% CI 14.3-39.3%]) or long-acting muscarinic agents (26.4% [95% CI 12.4-40.2%]). CONCLUSIONS: e-MEDRESP was successfully integrated in clinical practice. It could serve as a useful tool to help physicians monitor their patients' medication adherence.

Development of a community pharmacy-based intervention for patients with uncontrolled asthma.

Background: Achieving asthma control is often difficult, despite the availability of effective medications. Because of their expertise, regular contact with patients, and accessibility, community pharmacists can play an important role in helping patients manage uncontrolled asthma. Objective: To develop a community pharmacy-based intervention for improving asthma control in patients with uncontrolled moderate to severe asthma. Methods: A qualitative study involving two focus groups with six and five community pharmacists, respectively, five individual interviews with community pharmacists, and three individual interviews with asthma patients was conducted using semi-structured interview guides. Focus groups aimed to develop the first prototype of the intervention and the topics included criteria to identify patients with uncontrolled asthma, content of the intervention to manage uncontrolled asthma, and potential logistical issues. Interviews were subsequently conducted with individual pharmacists and asthma patients to evaluate the prototype and finalize the intervention. The interviews and focus group transcripts were analyzed thematically, using an iterative process. Results: In focus groups and interviews, the pharmacists discussed how they screen patients with uncontrolled asthma using prescriptions refills, their needs for a convenient tool to assess asthma control, the necessity to identify causes of uncontrolled asthma to guide asthma management strategies, and the importance of patient follow-up. During interviews, patients shared their interest for the commitment of pharmacists to managing asthma. The final intervention consists of structured face-to-face counselling sessions at community pharmacies, with six steps: screening of patients with potential uncontrolled moderate to severe asthma, assessment of asthma control, identification of the causes of uncontrolled asthma, strategies for controlling asthma, an optional follow-up at the next prescription refill, and a follow-up 3 months after the initial intervention. Conclusions: The patients and community pharmacists reached consensus on the intervention's key elements and provided support for implementing the intervention in community pharmacies.

Development of an operational definition of treatment escalation in adults with asthma adapted to healthcare administrative databases: A Delphi study.

BACKGROUND: In recent years, there has been growing interest in studying asthma treatment escalation patterns in the real-world setting, particularly with the advent of expensive biologic therapies. Healthcare administrative claims databases can be used to study treatment escalation patterns at a population-level; however, the reported definitions for claims-based asthma treatment escalation are highly variable in the literature. OBJECTIVE: The aim of this study was to develop an operational definition of treatment escalation in adults with asthma that can be applied to healthcare administrative data. METHODS: A mixed-methods research design incorporating the Delphi process was used to establish an expert consensus for this definition. A multi-disciplinary expert panel participated in three iterative rounds of online questionnaires covering treatment escalation criteria inspired by a systematic review, which was conducted as part of this study. The final definition was constructed using criteria for which a 75% level of agreement was achieved among the experts. RESULTS: We developed a claims-based treatment escalation definition that was adapted from the Global Initiative for Asthma (GINA) strategy. The definition comprised seven treatment steps, as well as escalation options for treatments that are not typically included in clinical guidelines. The definition also incorporated methods to identify treatments in severe asthma, such as oral corticosteroid maintenance therapy and chronic azithromycin use. CONCLUSIONS: The operational definition of treatment escalation developed in this study bridges the gap between clinical guidelines and real-world clinical practice and lays the groundwork for future observational studies on treatment escalation patterns among patients with asthma.

Resources Assessment for Penicillin Allergy Testing Performed by Pharmacists at the Patient's Bedside.

BACKGROUND: False penicillin allergies lead to increased antimicrobial resistance, adverse effects, and health care costs by promoting the use of broad-spectrum antibiotics. The Infectious Diseases Society of America recommends the implementation of allergy testing. OBJECTIVES: The primary objective of this research was to estimate the number of pharmacist full-time equivalents (FTEs) required for an intervention aimed at determining penicillin allergy in hospitalized patients. Acceptance of pharmacists' suggestions on antibiotic therapy are described. METHODS: A quasi-experimental study was conducted in a 712-bed university hospital involving hospitalized patients with a suspected penicillin allergy and an infection treatable with penicillin. The time required for the intervention, which included a questionnaire, penicillin allergy testing (skin-prick test, intradermal injection, and oral provocation test), and recommendations on antibiotic therapy were measured to calculate the number of pharmacist FTEs. RESULTS: A total of 55 patients were included. Scarification allergy testing was performed on 37, intradermal allergy test on 33, and oral provocation test on 26 patients. The intervention ruled out penicillin allergy in 26 patients, with no serious adverse effects. The intervention was associated with a median weekly pharmacist FTE of 0.15 (interquartile range = 0.12-0.25). The acceptance of pharmacists' suggestions was high and led to 9 patients being switched to an antibiotic with a narrower spectrum of activity. CONCLUSIONS AND RELEVANCE: This study describes penicillin allergy testing and the number of median weekly hospital pharmacist FTEs required, which was approximately 0.15. These data may aid in the implementation of this safe intervention that promotes narrower-spectrum antibiotherapy.

Development of an electronic tool (e-AdPharm) to address unmet needs and barriers of community pharmacists to provide medication adherence support to patients.

BACKGROUND: Community pharmacists are best placed to improve medication adherence because they frequently interact with patients and have been trained to manage medication-related problems. Therefore, it is essential to equip pharmacists adequately to detect non-adherent patients quickly and intervene to improve medication adherence. OBJECTIVE: To design e-AdPharm, a tool that addresses unmet needs and barriers of community pharmacists to provide medication adherence support to patients with chronic diseases. METHODS: A qualitative study using 4 focus group discussions with community pharmacists was conducted with a semi-structured interview guide and discussions lasting for 1-2 h. The discussions covered the barriers and needs of pharmacists related to medication adherence support provided to patients, their expectations of an electronic tool based on prescription refills to help them provide this support, and the design of the tool. Focus group data were coded and analyzed using an iterative process, with thematic and descriptive analyses. RESULTS: Twenty-six community pharmacists participated. Lack of time and motivation from pharmacists and patients were common barriers to the provision of medication adherence support. Accordingly, community pharmacists wished to measure medication adherence quickly, provide easily interpretable data to patients on their medication use, and raise the patient's awareness of non-adherence. The pharmacists expressed their need to have an electronic tool to share medication adherence information with the treating physician. Regarding the design of e-AdPharm, the pharmacists wanted a table displaying medication adherence with a color code representing adherence level. They also stressed the importance of a structured section enabling them to continuously document the interventions made and the need for patient follow-ups. CONCLUSIONS: e-AdPharm meet the needs and overcome the barriers of community pharmacists to provide medication adherence support to their patients. Future studies should examine the feasibility of implementing e-AdPharm in community pharmacies and test its efficacy for improving medication adherence.

Effects of reading media on reading comprehension in health professional education: a systematic review protocol.

OBJECTIVE: To evaluate the effect of digital-based reading versus paper-based reading on reading comprehension among students, trainees, and residents participating in health professional education. INTRODUCTION: Several reviews have examined the effects of reading media on reading comprehension; however, none have considered health professional education specifically. The growing use of electronic media in health professional education, as well as recent data on the consequences of digital-based reading on learning, justify the necessity to review the current literature to provide research and educational recommendations. INCLUSION CRITERIA: Studies conducted with health professions students, trainees, and residents individually receiving educational material written in their first language in a paper-based or a digital-based format will be considered. Studies conducted among participants with cognitive impairment or reading difficulties will be excluded. Observational, experimental and quasi-experimental studies that assess reading comprehension measured by previously validated or researcher-generated tests will be considered. METHODS: Relevant studies will be sought from CINAHL, Embase, ERIC, Google Scholar, MEDLINE, PsycINFO, and Web of Science (SCI and SSCI), without date or language restrictions. Two independent reviewers will perform title and abstract screening, full-text review, critical appraisal, and data extraction. Disagreements will be resolved through discussion or with a third independent reviewer. Synthesis will occur at four levels (i.e., study, participant, intervention, and outcome levels) in a table format. Data will be synthesized descriptively and with meta-analyses if appropriate. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO CRD42020154519.

Development of a Web-Based Tool Built From Pharmacy Claims Data to Assess Adherence to Respiratory Medications in Primary Care.

BACKGROUND: Medication adherence in asthma and COPD is notoriously low. To intervene effectively, family physicians need to assess adherence accurately, which is a challenging endeavor. In collaboration family physicians and individuals with asthma or COPD, we aimed to explore the barriers and facilitators of assessing medication adherence in clinical practice (exploratory phase), and to develop a novel web-based tool (e-MEDRESP) that will allow physicians to monitor adherence using pharmacy claims data (development phase). METHODS: We used qualitative research methods and a framework inspired by user-centered design principles. Five focus groups were held: 2 with subjects (n = 15) and 3 with physicians (n = 20), and 10 individual interviews were conducted with physicians. In the exploratory phase, data were analyzed using thematic networks. In the development phase, we identified components to be included in an e-MEDRESP prototype through an iterative approach. The web-based e-MEDRESP tool was constructed by applying algorithms to pharmacy claims data that reflected end-users' recommendations through an informatics approach designed for electronic medical records. RESULTS: The main barriers to assessing medication adherence included a lack of objective information regarding medication use and short duration of medical visits. Physicians emphasized that identifying patients at risk for nonadherence requires a team effort from pharmacists, respiratory therapists, and nurses. Subjects also agreed that the use of easily interpretable pharmacy claims data could be an important facilitator and contributed to the development of the e-MEDRESP prototype, which contains graphical representations of the adherence to respiratory controller medications and dispensing of rescue medications. CONCLUSIONS: The e-MEDRESP tool has the potential to allow physicians to measure adherence objectively and to facilitate patient-physician communication concerning medication use. Future studies are needed to evaluate the feasibility of implementing e-MEDRESP in clinical practice. It would be relevant to develop strategies that could facilitate the sharing of information presented in e-MEDRESP among primary care health professionals.

Monitoring and managing medication adherence in community pharmacies in Quebec, Canada.

BACKGROUND: Community pharmacists have direct access to prescription refill information and regularly interact with their patients. Therefore, they are in a unique position to promote optimal medication use. OBJECTIVES: To describe how community pharmacists in Quebec, Canada, identify nonadherent patients, monitor medication use and promote optimal medication adherence. METHODS: An invitation to complete a web-based survey was published online through different platforms, including a Facebook pharmacists' group, an electronic newsletter, a pharmacy network forum and e-mail. The survey included questions on participant characteristics, methods used by pharmacists to identify nonadherent patients and monitor medication use and interventions they used to promote medication adherence. RESULTS: In total, 342 community pharmacists completed the survey. The participants were mainly women (71.6%), staff pharmacists (56.7%) and aged 30 to 39 years (34.2%). The most common method to identify nonadherent patients was to check gaps between prescription refills (98.8%). The most common intervention to promote adherence was patient counselling (82.5%). The most common barriers to identifying nonadherent patients were lack of time (73.1%) and lack of prescription information (65.8%), whereas the most common barriers to intervening were anticipation of a negative reaction from their patients (91.2%) and lack of time (64%). CONCLUSION: Lack of time and lack of prescription information are frequent challenges encountered by community pharmacists regarding effective monitoring and management of patients with poor medication adherence. Pharmacists could benefit from electronic tools based on prescription refills that would provide quick and easily interpretable information on their patients' medication adherence. Can Pharm J (Ott) 2020;153:xx-xx.

Opinion, experience and educational preferences concerning pharmacogenomics: an exploratory study of Quebec pharmacists.

Aim: To evaluate the current opinion, experience and educational preferences of pharmacists in Quebec concerning pharmacogenomics. Method: A web-based survey containing 25 questions was sent to all Quebec pharmacists. Results: Most pharmacists were willing to advise patients (81%) and physicians (84%) on treatment choices based on pharmacogenomic test results after proper training. Only 31% had been previously exposed to pharmacogenomic test results, and 91% were favorable to pharmacogenomics training, with e-learning through interactive video sessions (69%). The preferred training session length was between 1 and 3 h (59%). Hospital pharmacists were more often exposed to pharmacogenomic tests (p < 0.0001) and more frequently advised patients on treatment choices (p < 0.001) than community pharmacists. Conclusion: Pharmacists remain favorable toward pharmacogenomics, but its use in clinical practice stays limited. Identifying the educational preferences of pharmacists may help in the development of educational programs to help them integrate pharmacogenomics in their clinical practice.

Conformity in Prescription and Administration of Respiratory Distress Protocols in a Tertiary Care Hospital in the Province of Quebec: RELIEVE Study.

BACKGROUND: Respiratory distress protocols (RDPs) are protocolized prescriptions comprised of 3 medications (a benzodiazepine, an opioid, and an anticholinergic) administered simultaneously as an emergency treatment for respiratory distress in palliative care patients in the province of Quebec, Canada. However, data on appropriate use that justifies the combination of all 3 components is scarce and based on individual pharmacodynamic properties along with expert consensus. OBJECTIVES: Our study aimed to evaluate the conformity and the effectiveness of RDPs prescribed and administered to hospitalized adult patients. METHODS: This was a prospective and descriptive study conducted in a single center. Prescription and administration conformity were assessed based on predefined appropriateness criteria. RESULTS: A total of 467 adult patients were prescribed a RDP, 175 administrations were documented, and 78 patients received at least 1 RDP. Prescription conformity was assessed on 1473 separate occasions over the trial period. Overall prescription conformity was found to be 37% (95% confidence interval [CI]: 33.6-40.4), and administration conformity was 37.7% (95% CI: 26.2-50.7). Low administration conformity was primarily explained by incorrect indications for RDP use. Seemingly important determinants of higher conformity were prescriber's speciality in palliative care, use of preprinted orders, pharmacist involvement, and hospitalization in the palliative care unit. CONCLUSION: This study highlights important gaps in the use of RDPs in our institution. Health-care provider training appears necessary in order to ensure adequate conformity and allow for further evaluation of RDP effectiveness.

Risk of Postpartum Depression Among Women with Asthma.

BACKGROUND: Several epidemiological studies have suggested that the risk of depression is increased in patients with asthma, but the impact of asthma during pregnancy on postpartum depression remains unknown. OBJECTIVE: To assess the association between maternal asthma and postpartum depression in a population-based cohort study retrieved from administrative databases. METHODS: A cohort of 35,520 pregnancies in women with asthma during pregnancy and 197,057 pregnancies in women without asthma who delivered between 1998 and 2009 was extracted from the Quebec Asthma and Pregnancy Database. They were followed from the day of delivery up to 1 year postpartum. A generalized estimating equation model was used to estimate the adjusted odds ratios of postpartum depression with 95% CIs in women with asthma during pregnancy versus women without asthma. RESULTS: Postpartum depression within 1 year after delivery occurred in 6.1% of women with asthma versus 2.9% of women without asthma. After adjusting for several potential confounders, including depression/postpartum depression up to 10 years before pregnancy, we found that women with asthma were 58% more likely to experience postpartum depression within 1 year after delivery than women without asthma during pregnancy (adjusted odds ratio, 1.58; 95% CI, 1.50-1.67). CONCLUSIONS: Our findings suggest that women with asthma are more likely to suffer from postpartum depression. A close monitoring of signs of depression for pregnant women with asthma is indicated, allowing prompt and efficient interventions if needed.

Long-Acting ß2-Agonists and Risk of Hypertensive Disorders of Pregnancy: A Cohort Study.

BACKGROUND: Maternal asthma has been found to be associated with an increased risk of hypertensive disorders of pregnancy (HDP), that is, gestational hypertension, preeclampsia, and eclampsia. There is limited data, however, regarding the relationship between the use of long-acting beta-agonists (LABAs) during pregnancy and these outcomes. OBJECTIVE: To investigate whether exposure to a LABA in addition to an inhaled corticosteroid increases the risk of HDP or preeclampsia/eclampsia, as compared with nonexposure to LABAs, in pregnant women with asthma. METHODS: A cohort of 8,936 pregnancies in women with asthma who delivered between 1998 and 2010 was reconstructed using Quebec (Canada) health administrative databases. Cox proportional hazard regression models, adjusted for potential confounders, were used for statistical analyses. The primary exposure was LABA use (yes/no) measured on the first day of the 20th week of pregnancy. HDP were identified on the basis of recorded diagnoses and on prescriptions of antihypertensive drugs filled on or after the first day of week 20 of gestation. RESULTS: There were 567 (6.3%) cases of HDP and 256 (2.9%) cases of preeclampsia/eclampsia in the cohort, and the rates of both disorders were similar in women exposed or not exposed to LABAs. LABA use was not associated with increased risks of HDP (adjusted hazard ratio, 0.96; 95% CI, 0.69-1.33) or preeclampsia/eclampsia (adjusted hazard ratio, 0.89; 95% CI, 0.53-1.50). CONCLUSIONS: The results of this study provide evidence suggesting the safety of LABAs for the treatment of asthma in pregnancy, in terms of the risks of HDP and preeclampsia/eclampsia.

The Quebec Respiratory Health Education Network: Integrating a model of self-management education in COPD primary care.

The objective of this study is to evaluate whether a chronic obstructive pulmonary disease (COPD) self-management education program with coaching of a case manager improves patient-related outcomes and leads to practice changes in primary care. COPD patients from six family medicine clinics (FMCs) participated in a 1-year educational program offered by trained case managers who focused on treatment adherence, inhaler techniques, smoking cessation, and the use of an action plan for exacerbations. Health-care utilization, health-related quality of life (HRQL), treatment adherence, inhaler technique, and COPD knowledge were assessed at each visit with validated questionnaires. We also evaluated whether the use of spirometry and the assessment of individual patient needs led to a more COPD-targeted treatment by primary care physicians, based on changes in prescriptions for COPD (medication, immunization, and written action plan). Fifty-four patients completed the follow-up visits and were included in the analysis. The number of unscheduled physician visits went from 40 the year before intervention to 17 after 1 year of educational intervention ( p = 0.033). Emergency room visits went from five to two and hospitalizations from two to three (NS). Significant improvements were observed in HRQL ( p = 0.0001), treatment adherence ( p = 0.025), adequate inhaler technique ( p < 0.0001), and COPD knowledge ( p < 0.001). Primary care physicians increased their prescriptions for long-acting bronchodilators with/without inhaled corticosteroid, flu immunizations, and COPD action plans in the event patient had an exacerbation. The COPD self-management educational intervention in FMCs reduced unscheduled visits to the clinic and improved patients' quality of life, self-management skills, and knowledge. The program had a positive impact on COPD-related practices by primary care physicians in the FMCs.

Preferences and Inhalation Techniques for Inhaler Devices Used by Patients with Chronic Obstructive Pulmonary Disease.

BACKGROUND: Inhaler technique and patient preferences are often overlooked when selecting maintenance treatments for patients with chronic obstructive pulmonary disease (COPD), but are important issues in ensuring drug efficacy and patient adherence. Few data on these issues are available for new inhalation devices. OBJECTIVES: To evaluate the inhalation techniques for the HandiHaler®, Breezhaler®, Genuair®, and Respimat® inhalation devices, and patient preferences for the three latter inhalers that were recently developed. METHODS: A prospective two-center cross-sectional study of COPD patients was conducted. The patients were required to be current HandiHaler users who had not previously used the new inhalers (Breezhaler, Genuair, Respimat). The patients were given the new devices and asked to identify the one they preferred before and after using the inhaler. Each patient tried the HandiHaler and two devices out of the three new inhalers: one preferred by the patient and one imposed by the investigator. Their inhalation technique was evaluated using an assessment checklist. A logistic regression model was used to determine which device was used with the fewest errors. RESULTS: Of the 98 patients who completed the study, 57.1% (95% CI: 47.4-66.9) had an adequate HandiHaler technique. There was no difference between the proportions of patients with an adequate Breezhaler and Genuair inhalation technique (aOR 1.08, 95% CI: 0.51-2.30), but 62% fewer patients using Respimat had an adequate technique than those using Genuair (aOR for adequate technique 0.38, 95% CI: 0.18-0.82). There were no significant differences in the initial patient preferences for the three new inhalers, and no association between the patient's preference and an adequate inhaler technique. CONCLUSION: Inhalation techniques were suboptimal and varied between inhalers. The arrival of new inhalers is an opportunity to reassess patient techniques and preferences. Further studies should also explore the association between the inhaler preferences and treatment adherence of patients.

Adherence and Persistence to Long-Acting Anticholinergics Treatment Episodes in Patients With Chronic Obstructive Pulmonary Disease.

BACKGROUND: No studies have examined adherence or persistence to long-acting anticholinergics (LAAC) treatment episodes in patients with chronic obstructive pulmonary disease (COPD). OBJECTIVE: To estimate 1-year adherence and 5-year persistence to LAAC during treatment episodes, and the likelihood of initiating a subsequent treatment episode. METHODS: A retrospective cohort of LAAC-treated COPD patients was reconstructed from Quebec databases. A treatment episode was initiated at cohort entry, defined as the first LAAC prescription date on/after the first COPD diagnosis date recorded between October 1, 2003, and March 31, 2014. We identified a subsequent treatment episode up to 5 years after the end of the episode initiated at cohort entry. We measured adherence as the proportion of days covered over 1 year. Persistence was defined as prescription renewal within 90 days of the previous prescription and was plotted using Kaplan-Meier curves over 5 years. The 5-year hazard and cumulative incidence of initiating a subsequent episode were estimated with survival analyses. We compared adherence and persistence between the treatment episodes using t and log-rank tests. RESULTS: The cohort included 113 435 COPD patients. Adherence and persistence to LAAC were significantly lower in the subsequent treatment episode (55% vs 63%; P < 0.0001). The likelihood of initiating a subsequent episode was greatest immediately after the cessation of the initial episode, with 59% of patients starting a subsequent episode within 1 year. CONCLUSION: Adherence and persistence to LAAC were lower in the subsequent treatment episode. Interventions should be offered quickly after LAAC cessation.