title: Determinants for changing the treatment of COPD: a regression analysis from a clinical audit.
abstract: BACKGROUND
  This study is an analysis of a pilot COPD clinical audit that evaluated adherence to guidelines for patients with COPD in a stable disease phase during a routine visit in specialized secondary care outpatient clinics in order to identify the variables associated with the decision to step-up or step-down pharmacological treatment.
  
  
  METHODS
  This study was a pilot clinical audit performed at hospital outpatient respiratory clinics in the region of Andalusia, Spain (eight provinces with over eight million inhabitants), in which 20% of centers in the area (catchment population 3,143,086 inhabitants) were invited to participate. Treatment changes were evaluated in terms of the number of prescribed medications and were classified as step-up, step-down, or no change. Three backward stepwise binominal multivariate logistic regression analyses were conducted to evaluate variables associated with stepping up, stepping down, and inhaled corticosteroids discontinuation.
  
  
  RESULTS
  The present analysis evaluated 565 clinical records (91%) of the complete audit. Of those records, 366 (64.8%) cases saw no change in pharmacological treatment, while 99 patients (17.5%) had an increase in the number of drugs, 55 (9.7%) had a decrease in the number of drugs, and 45 (8.0%) noted a change to other medication for a similar therapeutic scheme. Exacerbations were the main factor in stepping up treatment, as were the symptoms themselves. In contrast, rather than symptoms, doctors used forced expiratory volume in 1 second and previous treatment with long-term antibiotics or inhaled corticosteroids as the key determinants to stepping down treatment.
  
  
  CONCLUSIONS
  The majority of doctors did not change the prescription. When changes were made, a number of related factors were noted. Future trials must evaluate whether these therapeutic changes impact clinically relevant outcomes at follow-up.
authors.affiliation: Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Seville, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.
authors.forename: Jose Luis
authors.initials: JL
authors.lastname: López-Campos
authors.affiliation: Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Seville, Spain.
authors.forename: María
authors.initials: M
authors.lastname: Abad Arranz
authors.affiliation: Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Seville, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.
authors.forename: Carmen
authors.initials: C
authors.lastname: Calero Acuña
authors.affiliation: Hospital Universitario Puerta del Mar, Cádiz, Spain.
authors.forename: Fernando
authors.initials: F
authors.lastname: Romero Valero
authors.affiliation: Hospital Juan Ramón Jiménez, Huelva, Spain.
authors.forename: Ruth
authors.initials: R
authors.lastname: Ayerbe García
authors.affiliation: Hospital Universitario Puerta del Mar, Cádiz, Spain.
authors.forename: Antonio
authors.initials: A
authors.lastname: Hidalgo Molina
authors.affiliation: Hospital Juan Ramón Jiménez, Huelva, Spain.
authors.forename: Ricardo I
authors.initials: RI
authors.lastname: Aguilar Perez-Grovas
authors.affiliation: Hospital Universitario Reina Sofía, Córdoba, Spain.
authors.forename: Francisco
authors.initials: F
authors.lastname: García Gil
authors.affiliation: Hospital Universitario San Cecilio, Granada, Spain.
authors.forename: Francisco
authors.initials: F
authors.lastname: Casas Maldonado
authors.affiliation: Hospital Universitario Reina Sofía, Córdoba, Spain.
authors.forename: Laura
authors.initials: L
authors.lastname: Caballero Ballesteros
authors.affiliation: Hospital Universitario San Cecilio, Granada, Spain.
authors.forename: María
authors.initials: M
authors.lastname: Sánchez Palop
authors.affiliation: Hospital Infanta Margarita, Cabra, Córdoba, Spain.
authors.forename: Dolores
authors.initials: D
authors.lastname: Pérez-Tejero
authors.affiliation: Hospital Infanta Margarita, Cabra, Córdoba, Spain.
authors.forename: Alejandro
authors.initials: A
authors.lastname: Segado
authors.affiliation: Hospital Torrecárdenas, Almería, Spain.
authors.forename: Jose
authors.initials: J
authors.lastname: Calvo Bonachera
authors.affiliation: Hospital Torrecárdenas, Almería, Spain.
authors.forename: Bárbara
authors.initials: B
authors.lastname: Hernández Sierra
authors.affiliation: Hospital Regional Universitario de Málaga, Spain.
authors.forename: Adolfo
authors.initials: A
authors.lastname: Doménech
authors.affiliation: Hospital Regional Universitario de Málaga, Spain.
authors.forename: Macarena
authors.initials: M
authors.lastname: Arroyo Varela
authors.affiliation: Hospital Universitario Virgen de las Nieves, Granada, Spain.
authors.forename: Francisco
authors.initials: F
authors.lastname: González Vargas
authors.affiliation: Hospital Universitario Virgen de las Nieves, Granada, Spain.
authors.forename: Juan J
authors.initials: JJ
authors.lastname: Cruz Rueda
mesh_terms: D000280:Administration, Inhalation; D000305:Adrenal Cortex Hormones / Q000008:administration & dosage* / Q000009:adverse effects; D000368:Aged; D000900:Anti-Bacterial Agents / Q000008:administration & dosage; D001993:Bronchodilator Agents / Q000008:administration & dosage* / Q000009:adverse effects; D000066491:Clinical Decision-Making; D018450:Disease Progression; D011307:Drug Prescriptions; D004359:Drug Therapy, Combination; D005260:Female; D005541:Forced Expiratory Volume; D019983:Guideline Adherence; D006801:Humans; D016015:Logistic Models; D008168:Lung / Q000187:drug effects* / Q000503:physiopathology; D008297:Male; D008485:Medical Audit; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D010044:Outpatient Clinics, Hospital; D010641:Phenotype; D010865:Pilot Projects; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians'; D017064:Process Assessment, Health Care; D029424:Pulmonary Disease, Chronic Obstructive / Q000175:diagnosis / Q000188:drug therapy* / Q000503:physiopathology; D063127:Secondary Health Care; D016896:Treatment Outcome; D014797:Vital Capacity
chemical_list: D000305:Adrenal Cortex Hormones; D000900:Anti-Bacterial Agents; D001993:Bronchodilator Agents
keywords: airway diseases; follow-up; outpatient care; quality of care; respiratory diseases; treatment strategies