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      Estimation of the Clinical and Economic Impact of an Improvement in Adherence Based on the Use of Once-Daily Single-Inhaler Triple Therapy in Patients with COPD

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          Adherence to treatment is key to achieve desired outcomes. In COPD, adherence is generally suboptimal and is impaired by treatment complexity.


          To estimate the clinical and economic impact of an improvement in treatment adherence due to an increased use of once-daily single-inhaler triple therapy (SITT) in patients with COPD.

          Patients and Methods

          A 7-state Markov model with monthly cycles was developed. Patients with moderate-to-very severe COPD, for whom triple therapy is indicated, were included. Outcomes and costs were estimated and compared for two scenarios: current distribution of adherent patients treated with multiple inhaler triple therapies (MITT) vs a potential scenario where patients shifted to once-daily SITT. In the potential scenario, adherence improvement due to once-daily SITT attributes was estimated. Costing was based on the Spanish National Health System (NHS) perspective (€2019). A 3-year time horizon was defined considering a 3% discount rate for both costs and outcomes.


          A target population of 185,111 patients with moderate-to-very severe COPD currently treated with MITT was estimated. A 20% increase in the use of once-daily SITT in the potential scenario raised adherence up to 52%. This resulted in 6835 exacerbations and 532 deaths avoided, with 775 LYs and 594 QALYs gained. Total savings reached €7,082,105. Exacerbation reduction accounted for 61.8% (€4,378,201) of savings.


          Increasing the use of once-daily SITT in patients with moderate-to-very severe COPD treated with triple therapy would be associated with an improvement in adherence, a reduction of exacerbations and deaths, and cost savings for the Spanish NHS.

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          Most cited references 34

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          Prevalence of COPD in Spain: impact of undiagnosed COPD on quality of life and daily life activities.

          This study aimed to determine the prevalence of chronic obstructive pulmonary disease (COPD) in Spain and identify the level of undiagnosed disease and its impact on health-related quality of life (HRQL) and activities of daily living (ADL). A population-based sample of 4274 adults aged 40-80 years was surveyed. They were invited to answer a questionnaire and undergo prebrochodilator and postbronchodilator spirometry. COPD was defined as a postbronchodilator FEV(1)/FVC (forced expiratory volume in 1 s/forced vital capacity) ratio of <0.70. For 3802 participants with good-quality postbronchodilator spirometry, the overall prevalence of COPD was 10.2% (95% CI 9.2% to 11.1%) and was higher in men (15.1%) than in women (5.6%). The prevalence of COPD stage II or higher was 4.4% (95%CI; 3.8%-5.1%). The prevalence of COPD increased with age and with cigarette smoking and was higher in those with a low educational level. A previous diagnosis of COPD was reported by only 27% of those with COPD. Diagnosed patients had more severe disease, higher cumulative tobacco consumption and more severely impaired HRQL compared with undiagnosed subjects. However, even patients with undiagnosed COPD stage I+ already showed impairment in HRQL and in some aspects of ADL compared with participants without COPD. The prevalence of COPD in individuals between 40 and 80 years of age in Spain is 10.2% and increases with age, tobacco consumption and lower educational levels. The rate of diagnosised COPD is very high and undiagnosed individuals with COPD already have a significant impairment in HRQL and ADL.
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            Determinants of patient adherence: a review of systematic reviews

            Purpose: A number of potential determinants of medication non-adherence have been described so far. However, the heterogenic quality of existing publications poses the need for the use of a rigorous methodology in building a list of such determinants. The purpose of this study was a systematic review of current research on determinants of patient adherence on the basis of a recently agreed European consensus taxonomy and terminology. Methods: MEDLINE, EMBASE, CINAHL, Cochrane Library, IPA, and PsycINFO were systematically searched for systematic reviews published between 2000/01/01 and 2009/12/31 that provided determinants on non-adherence to medication. The searches were limited to reviews having adherence to medication prescribed by health professionals for outpatient as a major topic. Results: Fifty-one reviews were included in this review, covering 19 different disease categories. In these reviews, exclusively assessing non-adherence to chronic therapies, 771 individual factor items were identified, of which most were determinants of implementation, and only 47—determinants of persistence with medication. Factors with an unambiguous effect on adherence were further grouped into 8 clusters of socio-economic-related factors, 6 of healthcare team- and system-related factors, 6 of condition-related factors, 6 of therapy-related factors, and 14 of patient-related factors. The lack of standardized definitions and use of poor measurement methods resulted in many inconsistencies. Conclusions: This study provides clear evidence that medication non-adherence is affected by multiple determinants. Therefore, the prediction of non-adherence of individual patients is difficult, and suitable measurement and multifaceted interventions may be the most effective answer toward unsatisfactory adherence. The limited number of publications assessing determinants of persistence with medication, and lack of those providing determinants of adherence to short-term treatment identify areas for future research.
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              Adherence to inhaled therapies, health outcomes and costs in patients with asthma and COPD.

              Suboptimal adherence to pharmacological treatment of asthma and chronic obstructive pulmonary disease (COPD) has adverse effects on disease control and treatment costs. The reasons behind non-adherence revolve around patient knowledge/education, inhaler device convenience and satisfaction, age, adverse effects and medication costs. Age is of particular concern given the increasing prevalence of asthma in the young and increased rates of non-adherence in adolescents compared with children and adults. The correlation between adherence to inhaled pharmacological therapies for asthma and COPD and clinical efficacy is positive, with improved symptom control and lung function shown in most studies of adults, adolescents and children. Satisfaction with inhaler devices is also positively correlated with improved adherence and clinical outcomes, and reduced costs. Reductions in healthcare utilisation are consistently observed with good adherence; however, costs associated with general healthcare and lost productivity tend to be offset only in more adherent patients with severe disease, versus those with milder forms of asthma or COPD. Non-adherence is associated with higher healthcare utilisation and costs, and reductions in health-related quality of life, and remains problematic on an individual, societal and economic level. Further development of measures to improve adherence is needed to fully address these issues. Copyright © 2013. Published by Elsevier Ltd.

                Author and article information

                Int J Chron Obstruct Pulmon Dis
                Int J Chron Obstruct Pulmon Dis
                International Journal of Chronic Obstructive Pulmonary Disease
                10 July 2020
                : 15
                : 1643-1654
                [1 ]Pneumology Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut De Recerca (VHIR), Vall d’Hebron Hospital Campus , Barcelona, Spain
                [2 ]CIBER De Enfermedades Respiratorias (CIBERES) , Barcelona, Spain
                [3 ]Pneumology Department, Hospital Germans Trias I Pujol , Badalona, Spain
                [4 ]Market Access Department, GlaxoSmithKline SA , Madrid, Spain
                [5 ]Hygeia Consulting SL , Madrid, Spain
                [6 ]Barcelona School of Management, Universitat Pompeu Fabra (BSM-UPF) , Barcelona, Spain
                Author notes
                Correspondence: Marc Miravitlles Pneumology Department, Hospital Universitari Vall d’Hebron , P. Vall d’Hebron 119-129, Barcelona08035, Spain Tel/Fax +34 932746083 Email
                © 2020 Miravitlles et al.

                This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (

                Page count
                Figures: 4, Tables: 6, References: 49, Pages: 12
                Funded by: GlaxoSmithKline plc
                This study was funded by GlaxoSmithKline plc. (study number: HO-18-19453). Trademarks are owned by or licensed to their respective owners (the GlaxoSmithKline group of companies or AstraZeneca UK Ltd; Boehringer Ingelheim Ltd; Chiesi Ltd; or Novartis Pharmaceuticals UK Ltd). The abstract of this paper was presented at the European Respiratory Society International Congress 2019 name “Clinical and economic impact of an improvement in adherence based on specific attributes of single-inhaler triple therapies in COPD patients” as a poster presentation with interim findings. The poster’s abstract was published in the European Respiratory Journal 2019 Vol 54 Issue suppl 63: PA4194; DOI: 10.1183/13993003.congress-2019.PA4194. Available at: .
                Original Research

                Respiratory medicine

                economic evaluation, copd, healthcare, adherence


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