title: Economic assessment of early initiation of inhaled corticosteroids in chronic obstructive pulmonary disease using propensity score matching.
abstract: BACKGROUND
  Chronic obstructive pulmonary disease (COPD), characterized by airway obstruction and inflammation leading to chronic bronchitis and emphysema, is an important cause of morbidity, mortality, and increased health care utilization and expenditures.
  
  
  OBJECTIVE
  Observational data were used to examine potential benefits of inhaled corticosteroid (ICS) treatment initiated earlier than the current guideline-recommended stepwise approach among patients with COPD diagnosed between 1998 and 2004.
  
  
  METHODS
  Data for this retrospective cohort study of COPD patients aged > or = 40 years were drawn from a large managed care claims database. All patients received ICS therapy in addition to regular inhaled bronchodilator treatment. Annual exacerbation events, defined by COPD-related resource utilization (hospitalizations, emergency department visits, and/or unplanned office visits) and expenditures, were compared between patients with early initiation (ie, within 3 months of starting regular bronchodilators) and those who began ICS treatment later. Propensity score matching was used to identify treatment and control groups, controlling for baseline characteristics that could influence treatment choices and outcomes. Logistic and negative binomial regression models were used to estimate differences in utilization. Differences in medical, pharmacy, and total expenditures were estimated using a generalized linear model.
  
  
  RESULTS
  The study included 7712 patients (4146 females, 3566 males; mean age, 61.6 years). The mean duration of follow-up was 1040 days (2.8 years). Early ICS initiation was associated with a lower likelihood of mild (49.6% vs 56.3%; P < 0.001) and severe (20.9% vs 27.9%; P < 0.001) exacerbation events compared with later ICS initiation. Patients who began ICSs within 3 months had higher annual pharmacy expenditures ($1283 vs $1139; mean difference [95% CI], $145 [$106 to $187]) to treat COPD conditions. However, because of lower medical services use, early ICS initiation resulted in lower COPD-related medical expenditures ($1926 vs $2498; mean difference [95% CI], -$572 [-$835 to -$319]) and total expenditures ($3208 vs $3635; mean difference [95% CI], -$427 [-$704 to -$159]) per person annually. Early ICS initiation also was associated with lower all-cause medical expenditures but not lower total all-cause expenditures.
  
  
  CONCLUSIONS
  ICS treatment initiated along with bronchodilators reduced COPD exacerbation events and expenditures in these managed care plans. Further research is needed to address potential selection bias due to unobserved factors.
authors.affiliation: Department of Health Policy and Administration, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599-7411, USA.
authors.forename: Manabu
authors.initials: M
authors.lastname: Akazawa
authors.forename: Andrea K
authors.initials: AK
authors.lastname: Biddle
authors.forename: Sally C
authors.initials: SC
authors.lastname: Stearns
mesh_terms: D000280:Administration, Inhalation; D000328:Adult; D000368:Aged; D001993:Bronchodilator Agents / Q000627:therapeutic use; D015331:Cohort Studies; D003365:Costs and Cost Analysis; D004359:Drug Therapy, Combination; D005260:Female; D005938:Glucocorticoids / Q000008:administration & dosage / Q000191:economics* / Q000627:therapeutic use*; D006296:Health Services / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D029424:Pulmonary Disease, Chronic Obstructive / Q000188:drug therapy* / Q000191:economics*; D012189:Retrospective Studies
chemical_list: D001993:Bronchodilator Agents; D005938:Glucocorticoids