TY - JOUR
T1 - Variability of antibiotic prescribing in patients with chronic obstructive pulmonary disease exacerbations
T2 - A cohort study
AU - Boggon, Rachael
AU - Hubbard, Richard
AU - Smeeth, Liam
AU - Gulliford, Martin
AU - Cassell, Jackie
AU - Eaton, Susan
AU - Pirmohamed, Munir
AU - van Staa, Tjeerd Pieter
N1 - Funding Information:
The study was funded by the NIHR HTA programme as part of implementing a pilot pragmatic randomised trial for the comparative effectiveness of antibiotics in patients with an exacerbation of chronic obstructive pulmonary disease and non-purulent sputum.
Funding Information:
CPRD has received funding from the Medicines and Healthcare products Rregulatory Agency, Wellcome Trust, Medical Research Council, National Institute for Health Research Health Technology Assessment programme (NIHR HTA programme), Innovative Medicine Initiative, UK Department of Health, Technology Strategy Board, Seventh Framework Programme EU, various universities, contract research organisations and pharmaceutical companies. The department of Pharmacoepidemiology & Pharmacotherapy, Utrecht Institute for Pharmaceutical Sciences has received unrestricted funding for pharmacoepidemiological research from GlaxoSmithKline, Novo Nordisk, the private-public funded Top Institute Pharma (http://www.tipharma.nl, includes co-funding from universities, government, and industry), the Dutch Medicines Evaluation Board, and the Dutch Ministry of Health.
PY - 2013/5/31
Y1 - 2013/5/31
N2 - Background: The role of antibiotics in treating mild or moderate exacerbations in patients with acute chronic obstructive pulmonary disease (COPD) is unclear. The aims were to: (i) describe patient characteristics associated with acute exacerbations amongst a representative COPD population, (ii) explore the relationship between COPD severity and outcomes amongst patients with exacerbations, and (iii) quantify variability by general practice in prescribing of antibiotics for COPD exacerbations. Method: A cohort of 62,747 patients with COPD was identified from primary care general practices (GP) in England, and linked to hospital admission and death certificate data. Exacerbation cases were matched to three controls and characteristics compared using conditional logistic regression. Outcomes were compared using incidence rates and Cox regression, stratified by disease severity. Variability of prescribing at the GP level was evaluated graphically and by using multilevel models. Results: COPD severity was found to be associated with exacerbation and subsequent mortality (very severe vs. mild, odds ratio for exacerbation 2.12 [95%CI 19.5-2.32]), hazard ratio for mortality 2.14 [95%CI 1.59-2.88]). Whilst 61% of exacerbation cases were prescribed antibiotics, this proportion varied considerably between GP practices (interquartile range, 48-73%). This variation is greater than can be explained by patient characteristics alone. Conclusions: There is significant variability between GP practices in the prescribing of antibiotics to COPD patients experiencing exacerbations. Combined with a lack of evidence on the effects of treatment, this supports the need and opportunity for a large scale pragmatic randomised trial of the prescribing of antibiotics for COPD patients with exacerbations, in order to clarify their effectiveness and long term outcomes whilst ensuring the representativeness of subjects.
AB - Background: The role of antibiotics in treating mild or moderate exacerbations in patients with acute chronic obstructive pulmonary disease (COPD) is unclear. The aims were to: (i) describe patient characteristics associated with acute exacerbations amongst a representative COPD population, (ii) explore the relationship between COPD severity and outcomes amongst patients with exacerbations, and (iii) quantify variability by general practice in prescribing of antibiotics for COPD exacerbations. Method: A cohort of 62,747 patients with COPD was identified from primary care general practices (GP) in England, and linked to hospital admission and death certificate data. Exacerbation cases were matched to three controls and characteristics compared using conditional logistic regression. Outcomes were compared using incidence rates and Cox regression, stratified by disease severity. Variability of prescribing at the GP level was evaluated graphically and by using multilevel models. Results: COPD severity was found to be associated with exacerbation and subsequent mortality (very severe vs. mild, odds ratio for exacerbation 2.12 [95%CI 19.5-2.32]), hazard ratio for mortality 2.14 [95%CI 1.59-2.88]). Whilst 61% of exacerbation cases were prescribed antibiotics, this proportion varied considerably between GP practices (interquartile range, 48-73%). This variation is greater than can be explained by patient characteristics alone. Conclusions: There is significant variability between GP practices in the prescribing of antibiotics to COPD patients experiencing exacerbations. Combined with a lack of evidence on the effects of treatment, this supports the need and opportunity for a large scale pragmatic randomised trial of the prescribing of antibiotics for COPD patients with exacerbations, in order to clarify their effectiveness and long term outcomes whilst ensuring the representativeness of subjects.
KW - Anti-bacterial agents
KW - Chronic obstructive pulmonary disease
KW - Clinical practice variation
KW - Disease exacerbation
KW - General practice
KW - Primary health care
UR - http://www.scopus.com/inward/record.url?scp=84878361508&partnerID=8YFLogxK
U2 - 10.1186/1471-2466-13-32
DO - 10.1186/1471-2466-13-32
M3 - Article
C2 - 23724907
AN - SCOPUS:84878361508
SN - 1471-2466
VL - 13
JO - BMC Pulmonary Medicine
JF - BMC Pulmonary Medicine
IS - 1
M1 - 32
ER -
