Multidimensional analyses to assess the relations between treatment choices by physicians and patients’ characteristics: the example of COPD

BMC Pulmonary Medicine

Bruno Scherrer³  Hervé Pégliasco⁴  Jean-Michel Marcos⁶  Yan Martinat¹  Bertrand Delclaux⁷  Christos Chouaid⁵  Nicolas Roche² 

[1] Parrot Medical Centre, Lyon, France;Respiratory and Intensive Care Medicine, Hôtel-Dieu Hospital, AP-HP, University Paris Descartes, Paris, France;Bruno Scherrer Conseil, Saint-Arnoult en Yvelines, France;Respiratory Medicine, Clinique Ambroise Paré, Marseille, France;Respiratory Medicine, Hôpital Saint-Antoine, AP-HP, University Pierre et Marie Curie, Paris, France;Respiratory Medicine, Libourne Hospital, Libourne, France;Respiratory Medicine, Troyes Hospital, Troyes, France

关键词: Guidelines;    Management;    Treatment;    Phenotype;    Factor analysis;    COPD;   

Others  :  1161080
DOI  :  10.1186/1471-2466-12-39

 received in 2011-11-01, accepted in 2012-07-26,  发布年份 2012

【 摘 要 】

Background

In some situations, practice guidelines do not provide firm evidence-based guidance regarding COPD treatment choices, especially when large trials have failed to identify subgroups of particularly good or poor responders to available medications.

Methods

This observational cross-sectional study explored the yield of four types of multidimensional analyses to assess the associations between the clinical characteristics of COPD patients and pharmacological and non-pharmacological treatments prescribed by lung specialists in a real-life context.

Results

Altogether, 2494 patients were recruited by 515 respiratory physicians. Multiple correspondence analysis and hierarchical clustering identified 6 clinical subtypes and 6 treatment subgroups. Strong bi-directional associations were found between clinical subtypes and treatment subgroups in multivariate logistic regression. However, although the overall frequency of prescriptions varied from one clinical subtype to the other for all types of pharmacological treatments, clinical subtypes were not associated with specific prescription profiles. When canonical analysis of redundancy was used, the proportion of variation in pharmacological treatments that was explained by clinical characteristics remained modest: 6.23%. This proportion was greater (14.29%) for non-pharmacological components of care.

Conclusion

This study shows that, although pharmacological treatments of COPD are quantitatively very well related to patients’ clinical characteristics, there is no particular patient profile that could be qualitatively associated to prescriptions. This underlines uncertainties perceived by physicians for differentiating the respective effects of available pharmacological treatments. The methodology applied here is useful to identify areas of uncertainty requiring further research and/or guideline clarification.

【 授权许可】

   
2012 Roche et al.; licensee BioMed Central Ltd.

【 参考文献 】

• [1]National Heart Lung and Blood Institute: Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management and prevention of chronic obstructive lung disease, NIH, World Health Organization; 2009. updated 2011. http://www.goldcopd.com webcite. Last access August 1st, 2012
• [2]Tashkin DP, Celli B, Senn S, Burkhart D, Kesten S, Menjoge S, Decramer M: A 4-year trial of tiotropium in chronic obstructive pulmonary disease. N.Engl.J Med 2008, 359:1543-1554.
• [3]Calverley PM, Anderson JA, Celli B, Ferguson GT, Jenkins C, Jones PW, Yates JC, Vestbo J: Salmeterol and fluticasone propionate and survival in chronic obstructive pulmonary disease. N Engl J Med 2007, 356:775-789.
• [4]O’Donnell DE, Voduc N, Fitzpatrick M, Webb KA: Effect of salmeterol on the ventilatory response to exercise in chronic obstructive pulmonary disease. Eur Respir J 2004, 24:86-94.
• [5]O’Donnell DE, Fluge T, Gerken F, Hamilton A, Webb K, Aguilaniu B, Make B, Magnussen H: Effects of tiotropium on lung hyperinflation, dyspnoea and exercise tolerance in COPD. Eur Respir J 2004, 23:832-840.
• [6]Celli B, Decramer M, Kesten S, Liu D, Mehra S, Tashkin DP: Mortality in the 4-year trial of tiotropium (UPLIFT) in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2009, 180:948-955.
• [7]Celli BR, Thomas NE, Anderson JA, Ferguson GT, Jenkins CR, Jones PW, Vestbo J, Knobil K, Yates JC, Calverley PM: Effect of pharmacotherapy on rate of decline of lung function in chronic obstructive pulmonary disease: results from the TORCH study. Am J Respir Crit Care Med. 2008, 178:332-338.
• [8]Decramer M, De Benedetto F, Del Ponte A, Marinari S: Systemic effects of COPD. Respir Med 2005, 99(Suppl B):S3-S10.
• [9]Ries AL, Bauldoff GS, Carlin BW, Casaburi R, Emery CF, Mahler DA, Make B, Rochester CL, ZuWallack R, Herrerias C: Pulmonary Rehabilitation: Joint ACCP/AACVPR Evidence-Based Clinical Practice Guidelines. Chest. 2007, 131:4S-42S.
• [10]Hurst JR, Vestbo J, Anzueto A, Locantore N, Müllerova H, Tal-Singer R, Miller B, Lomas DA, Agusti A, Macnee W, Calverley P, Rennard S, Wouters EFM, Wedzicha JA: Susceptibility to exacerbation in chronic obstructive pulmonary disease. N. Engl. J. Med 2010, 363:1128-1138.
• [11]Burgel PR, Nesme-Meyer P, Chanez P, Caillaud D, Carre P, Perez T, Roche N: Cough and sputum production are associated with frequent exacerbations and hospitalizations in COPD subjects. Chest. 2009, 135:975-982.
• [12]Tatsumi K, Kasahara Y, Kurosu K, Tanabe N, Takiguchi Y, Kuriyama T: Clinical phenotypes of COPD: results of a Japanese epidemiological survey. Respirology. 2004, 9:331-336.
• [13]Burgel PR, Paillasseur JL, Caillaud D, Tillie-Leblond I, Chanez P, Escamilla R, Court-Fortune, Perez T, Carre P, Roche N: Clinical COPD phenotypes: a novel approach using principal component and cluster analyses. Eur Respir J 2010, 36:531-539.
• [14]Celli BR, Cote CG, Marin JM, Casanova C, de Montes O, Mendez RA, Pinto P, Cabral HJ: The body-mass index, airflow obstruction, dyspnea, and exercise capacity index in chronic obstructive pulmonary disease. N Engl J Med 2004, 350:1005-1012.
• [15]Tashkin DP, Cooper CB: The role of long-acting bronchodilators in the management of stable COPD. Chest 2004, 125:249-259.
• [16]Aaron SD, Vandemheen KL, Fergusson D, Maltais F, Bourbeau J, Goldstein R, Balter M, O’Donnell D, McIvor A, Sharma S, Bishop G, Anthony J, Cowie R, Field S, Hirsch A, Hernandez P, Rivington R, Road J, Hoffstein V, Hodder R, Marciniuk D, McCormack D, Fox G, Cox G, Prins HB, Ford G, Bleskie D, Doucette S, Mayers I, Chapman K, Zamel N, Fitzgerald M: Tiotropium in combination with placebo, salmeterol, or fluticasone-salmeterol for treatment of chronic obstructive pulmonary disease: a randomized trial. Ann Intern Med. 2007, 146:545-555.
• [17]Wedzicha JA, Calverley PM, Seemungal TA, Hagan G, Ansari Z, Stockley RA: The prevention of chronic obstructive pulmonary disease exacerbations by salmeterol/fluticasone propionate or tiotropium bromide. Am J Respir Crit Care Med. 2008, 177:19-26.
• [18]Jenkins CR, Jones PW, Calverley PM, Celli B, Anderson JA, Ferguson GT, Yates JC, Willits LR, Vestbo J: Efficacy of salmeterol/fluticasone propionate by GOLD stage of chronic obstructive pulmonary disease: analysis from the randomised, placebo-controlled TORCH study. Respir Res 2009, 10:59-59. BioMed Central Full Text
• [19]Tashkin DP, Celli B, Kesten S, Lystig T, Mehra S, Decramer M: Long-term efficacy of tiotropium in relation to smoking status in the UPLIFT trial. Eur. Respir. J. 2010, 35:287-294.
• [20]Tashkin D, Celli B, Kesten S, Lystig T, Decramer M: Effect of tiotropium in men and women with COPD: Results of the 4-year UPLIFT((R)) trial. Respir Med. 2010, 104:1495-1504.
• [21]Fitch K, Iwasaki K, Pyenson B, Plauschinat C, Zhang J: Variation in adherence with Global Initiative for Chronic Obstructive Lung Disease (GOLD) drug therapy guidelines: a retrospective actuarial claims data analysis. Curr Med Res Opin 2011, 27:1425-1429.
• [22]Roche N, Lepage T, Bourcereau J, Terrioux P: Guidelines versus clinical practice in the treatment of chronic obstructive pulmonary disease. Eur. Respir J. 2001, 18:903-908.
• [23]Jebrak G, for Initiatives BPCO, for Initiatives BPCO: COPD routine management in France: are guidelines used in clinical practice? Rev Mal Respir 2010, 27:11-18.
• [24]de Marco R, Accordini S, Cerveri I, Corsico A, Sunyer J, Neukirch F, Kunzli N, Leynaert B, Janson C, Gislason T, Vermeire P, Svanes C, Anto JM, Burney P: An international survey of chronic obstructive pulmonary disease in young adults according to GOLD stages. Thorax 2004, 59:120-125.
• [25]Legendre P, Legendre L: Numerical ecology. Elsevier, Amsterdam; 1999.
• [26]Scherrer B: Biostatistique. G. Morin, Montréal; 2009.
• [27]Lebreton JD, Sabatier R, Banco G, Bacou AM: Principal component and correspondence analysis with respect to instrumental variables: an overview of their role in studies of structures-activity and species environment relationships. Applied multivariate in SAR and environmental studies 1991, 85-114.
• [28]Boulet L-P, Becker A, Bowie D, Hernandez P, McIvor A, Rouleau M: Implementing practice guidelines: A workshop on guidelines dissemination and implementation with a focus on asthma and COPD. Can Respir J 2006, 13(Suppl A):5A-47A.