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      Economic impact of delaying initiation with multiple-inhaler maintenance triple therapy in Spanish patients with chronic obstructive pulmonary disease

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          Guidelines recommend the use of triple therapy with an inhaled corticosteroid (ICS), a long-acting β 2 agonist (LABA) and a long-acting muscarinic antagonist (LAMA) to reduce the risk of future exacerbations in symptomatic COPD patients with a history of exacerbations. This study aimed to estimate COPD-related healthcare resource use and costs, and subsequent exacerbation rates, for patients initiating multiple-inhaler triple therapy (MITT) early (≤30 days) versus late (31–180 days) following an exacerbation, in a real-world clinical setting.

          Patients and methods

          This was an observational, longitudinal, retrospective study using electronic medical records from the Spanish database of the Red de Investigación en Servicios Sanitarios Foundation. Patients ≥40 years old with a confirmed COPD diagnosis who were newly prescribed MITT up to 180 days after an exacerbation between January 2013 and December 2015 were included. Patients were followed from the date of MITT initiation for up to 12 months to assess COPD-related health care resource use (routine and emergency visits, hospitalizations, pharmacologic treatment), exacerbation rate, and costs (€2017); these endpoints were compared between early versus late groups.


          The study included 1280 patients who met selection criteria: mean age 73 years, 78% male, and 41% had severe/very severe lung function impairment. The proportion of patients initiating MITT early versus late was 61.6% versus 38.4%, respectively. There were no statistically significant differences in baseline characteristics between groups. During follow-up, health care resource consumption was lower in the early versus late group, especially primary care and ED visits, leading to lower total costs (€1861 versus €1935; P<0.05). In the follow-up period, 28.0% of the patients in the early group experienced ≥1 exacerbation versus 36.4% in the late group ( P=0.002), with an exacerbation rate of 0.5 versus 0.6 per person per year ( P=0.022), respectively.


          Initiating MITT early (≤30 days after an exacerbation) may reduce health care costs and exacerbation rate compared with late MITT initiation.

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          Most cited references 10

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          Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper.

           W MacNee,  ,  B Celli (2004)
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            Treatment patterns in COPD patients newly diagnosed in primary care. A population-based study.

            Treatment for COPD is tailored based on clinical characteristics and severity. However, prescription patterns in COPD patients newly diagnosed in primary care may differ from guideline recommendations.
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              Is Open Access

              Clinical audit of COPD in outpatient respiratory clinics in Spain: the EPOCONSUL study

              Background Chronic obstructive pulmonary disease (COPD) outpatients account for a large burden of usual care by respirologists. EPOCONSUL is the first national clinical audit conducted in Spain on the medical care for COPD patients delivered in outpatient respiratory clinics. We aimed to evaluate the clinical interventions and the degree of adherence to recommendations in outpatients of current COPD clinical practice guidelines. Methodology This is an observational study with prospective recruitment (May 2014–May 2015) of patients with a COPD diagnosis as seen in outpatient respiratory clinics. The information collected was historical in nature as for the clinical data of the last and previous consultations, and the information concerning hospital resources was concurrent. Results A total of 17,893 clinical records of COPD patients in outpatient respiratory clinics from 59 Spanish hospitals were evaluated. Of the 5,726 patients selected, 4,508 (78.7%) were eligible. Overall, 12.1% of COPD patients did not fulfill a diagnostic spirometry criteria. Considerable variability existed in the available resources and work organization of the hospitals, although the majority were university hospitals with respiratory inpatient units. There was insufficient implementation of clinical guidelines in preventive and educational matters. In contrast, quantitative evaluation of dyspnea grade (81.9%) and exacerbation history (70.9%) were more frequently performed. Only 12.4% had COPD severity calculated according to the Body mass index, airflow Obstruction, Dyspnoea and Exercise capacity (BODE) index. Phenotype characteristics according to Spanish National Guideline for COPD were determined in 46.3% of the audited patients, and the risk evaluation according to Global initiative for chronic Obstructive Lung Disease was estimated only in 21.9%. Conclusion The EPOCONSUL study reports the current situation of medical care for COPD patients in outpatient clinics in Spain, revealing its variability, strengths, and weaknesses. This information has to be accounted for by health managers to define corrective strategies and maximize good clinical practice.

                Author and article information

                Int J Chron Obstruct Pulmon Dis
                Int J Chron Obstruct Pulmon Dis
                International Journal of Chronic Obstructive Pulmonary Disease
                12 September 2019
                : 14
                : 2121-2129
                [1 ]Scientific Direction, Health Economics and Outcomes Research (HEOR) Department, Real Life Data , Madrid, Spain
                [2 ]Market Access Department, GlaxoSmithKline SA , Madrid, Spain
                [3 ]Medical Documentation Department, Hospital Germans Trias I Pujol , Badalona, Spain
                [4 ]Pulmonology Service, Hospital Parc Taulí , Barcelona, Spain
                [5 ]CIBERES – Ciber De Enfermedades Respiratorias , Madrid, Spain
                [6 ]Real World Evidence and Epidemiology Department, GlaxoSmithKline , Uxbridge, UK
                [7 ]Value Evidence and Outcomes Department, GlaxoSmithKline , Collegeville, PA, USA
                [8 ]Department of Health Research Methods, Evidence and Impact, McMaster University , Hamilton, ON, Canada
                Author notes
                Correspondence: Alicia HuertaMarket Access Department, GlaxoSmithKline SA , C/Severo Ochoa 2, Madrid28760, SpainTel +34 91 807 0821Fax +34 9 187 0500Email
                © 2019 Sicras Mainar 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: 2, Tables: 5, References: 21, Pages: 9
                Original Research

                Respiratory medicine

                inhaled corticosteroid, copd, exacerbations, costs, triple therapy


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