Back to Journals » Clinical Epidemiology » Volume 12

Geographical and sociodemographic differences in discontinuation of medication for Chronic Obstructive Pulmonary Disease – A Cross-Classified Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA)

Authors Khalaf K, Axelsson Fisk S, Ekberg-Jansson A, Leckie G, Perez-Vicente R, Merlo J

Received 27 January 2020

Accepted for publication 11 May 2020

Published 20 July 2020 Volume 2020:12 Pages 783—796


Checked for plagiarism Yes

Review by Single anonymous peer review

Peer reviewer comments 3

Editor who approved publication: Professor Vera Ehrenstein

Kani Khalaf,1,* Sten Axelsson Fisk,1,* Ann Ekberg-Jansson,2,3 George Leckie,1,4 Raquel Perez-Vicente,1 Juan Merlo1,5

1Unit for Social Epidemiology, Faculty of Medicine, Lund University, Malmö, Sweden; 2Department of Research and Development, Region Halland, Halmstad, Sweden; 3Department of Internal Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; 4Centre for Multilevel Modelling, University of Bristol, Bristol, UK; 5Center for Primary Health Care Research, Region Skåne, Malmö, Sweden

*These authors contributed equally to this work

Correspondence: Kani Khalaf Email

Background: 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).
Patients and Methods: 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.
Results: 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).
Conclusion: 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.

Keywords: COPD, socioeconomic inequity, multilevel analysis, equity in health care, health care quality, compliance, discriminatory accuracy

Creative Commons License 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.

Download Article [PDF]  View Full Text [HTML][Machine readable]