Khalaf Kani, Axelsson Fisk Sten, Ekberg-Jansson Ann, Leckie George, Perez-Vicente Raquel, Merlo Juan
Unit for Social Epidemiology, Faculty of Medicine, Lund University, Malmö, Sweden.
Department of Research and Development, Region Halland, Halmstad, Sweden.
Clin Epidemiol. 2020 Jul 20;12:783-796. doi: 10.2147/CLEP.S247368. eCollection 2020.
While discontinuation of COPD maintenance medication is a known problem, the proportion of patients with discontinuation and its geographical and sociodemographic distribution are so far unknown in Sweden. Therefore, we analyse this question by applying an innovative approach called multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA).
We analysed 49,019 patients categorized into 18 sociodemographic contexts and 21 counties of residence. All patients had a hospital COPD diagnosis and had been on inhaled maintenance medication during the 5 years before the study baseline in 2010. We defined "discontinuation" as the absolute lack of retrieval from a pharmacy of any inhaled maintenance medication during 2011. We performed a cross-classified MAIHDA and obtained the average proportion of discontinuation, as well as county and sociodemographic absolute risks, and compared them with a proposed benchmark value of 10%. We calculated the variance partition coefficient (VPC) and the area under the receiver operating characteristics curve (AUC) to quantify county and sociodemographic differences. To summarize the results, we used a framework with 15 scenarios defined by the size of the differences and the level of achievement in relation to the benchmark value.
Around 18% of COPD patients in Sweden discontinued maintenance medication, so the benchmark value was not achieved. There were very small county differences (VPC=0.35%, AUC=0.54). The sociodemographic differences were small (VPC=4.98%, AUC=0.57).
Continuity of maintenance medication among COPD patients in Sweden could be improved by reducing the unjustifiably high prevalence of discontinuation. The very small county and small sociodemographic differences should motivate universal interventions across all counties and sociodemographic groups. Geographical analyses should be combined with sociodemographic analyses, and the cross-classified MAIHDA is an appropriate tool to assess health-care quality.
虽然慢性阻塞性肺疾病（COPD）维持药物治疗中断是一个已知问题，但在瑞典，治疗中断患者的比例及其地理和社会人口分布情况目前尚不清楚。因此，我们通过应用一种名为个体异质性和鉴别准确性多水平分析（MAIHDA）的创新方法来分析这个问题。
我们分析了49019名患者，这些患者被分为18种社会人口背景和21个居住县。所有患者均被诊断为患有医院型COPD，并且在2010年研究基线前的5年中一直在使用吸入性维持药物治疗。我们将“治疗中断”定义为在2011年期间药房绝对没有任何吸入性维持药物的取药记录。我们进行了交叉分类的MAIHDA分析，得出了治疗中断的平均比例、各县以及社会人口的绝对风险，并将其与提议的10%的基准值进行比较。我们计算了方差划分系数（VPC）和受试者操作特征曲线下面积（AUC），以量化各县和社会人口之间的差异。为了总结结果，我们使用了一个由差异大小和相对于基准值的达成水平定义的包含15种情况的框架。
瑞典约18%的COPD患者中断了维持药物治疗，因此未达到基准值。各县之间的差异非常小（VPC = 0.35%，AUC = 0.54）。社会人口差异较小（VPC = 4.98%，AUC = 0.57）。
通过降低不合理的高治疗中断率，可以改善瑞典COPD患者维持药物治疗的连续性。各县之间非常小的差异以及社会人口方面较小的差异应该促使对所有县和社会人口群体采取普遍干预措施。地理分析应与社会人口分析相结合，而交叉分类的MAIHDA是评估医疗质量的合适工具。
