Advanced machine learning models for prediction of readmission and mortality risks in patients with chronic obstructive pulmonary disease using routine clinical data

The relationship between the Charlson comorbidity index (CCI) and short-term readmission is as yet unknown. Therefore, we aimed to investigate whether the CCI was independently related to short-term readmission in patients with heart failure (HF) after adjusting for other covariates. From December 2016 to June 2019, 2008 patients who underwent HF were enrolled in the study to determine the relationship between CCI and short-term readmission. Patients with HF were divided into 2 categories based on the predefined CCI (low < 3 and high > =3). The relationships between CCI and short-term readmission were analyzed in multivariable logistic regression models and a 2-piece linear regression model. In the high CCI group, the risk of short-term readmission was higher than that in the low CCI group. A curvilinear association was found between CCI and short-term readmission, with a saturation effect predicted at 2.97. In patients with HF who had CCI scores above 2.97, the risk of short-term readmission increased significantly (OR, 2.66; 95% confidence interval, 1.566-4.537). A high CCI was associated with increased short-term readmission in patients with HF, indicating that the CCI could be useful in estimating the readmission rate and has significant predictive value for clinical outcomes in patients with HF.

Year in review 2017: Chronic obstructive pulmonary disease and asthma.

Background: Acute exacerbation is the most common cause of hospitalization for patients with chronic obstructive pulmonary disease (COPD). Objectives: To investigate prognostic factors associated with poor outcomes after acute exacerbation of COPD. Methods: A retrospective study of patients with a diagnosis of acute exacerbation of COPD (AECOPD) admitted to hospital in Penang over 5-year periods between January 2007 and December 2011 were conducted. We analyzed survival data using a Kaplan–Meier curves, and Cox regression was used to identify prognostic factors for mortality and readmission. Results: The study included 259 patients with a median age of 70 years (interquartile range = 59.7–76.7 years), and men comprised 92.7% of the cohort. Mortality after 1, 3, and 5 years was 26.3%, 49.8%, and 59.5% respectively. Older age (hazard ratio (HR), 2.53; 95% confidence interval (CI), 1.29–4.92) and long-term oxygen therapy (LTOT) at discharge (HR, 2.78; 95% CI, 1.54–5.02) were identified as independent prognostic factors associated with a higher risk of mortality after discharge. The risk of hospital readmission was 34% for 1 year, 43.2% for 3 years, and 48.6% for 5 years. Older age (HR, 1.78; 95% CI, 1.12–2.85), LTOT at discharge (HR, 3.63; 95% CI, 1.89–6.95), frequency of admissions in the previous year (HR, 2.92; 95% CI, 1.47–5.80), and being ventilated (HR, 0.19; 95% CI, 0.08–0.47) were identified as prognostic factors associated with readmission. Conclusions: Patients surviving AECOPD were prone to poor outcomes. Older patients and those discharged with LTOT were at higher risk of mortality and readmission at any time. Keywords: COPD, exacerbation, mortality, patient readmission, prognosis

Efforts to reduce 30-day readmission have mostly concentrated on addressing deficiencies in care transitions and outpatient management after discharge. There is growing evidence to suggest that physical inactivity is associated with increased hospitalizations. We examined whether or not a potentially modifiable factor such as regular physical activity at baseline was associated with lower risk of 30-day readmission in patients with chronic obstructive pulmonary disease (COPD). Patients from a large integrated health system were included in this retrospective cohort study if they were hospitalized for COPD (following the Centers for Medicare and Medicaid Services and National Quality Forum proposed criteria) and discharged between January 1, 2011 and December 31, 2012, aged 40 years or older, on a bronchodilator or steroid inhaler, alive at discharge, and continuously enrolled in the health plan 12 months before the index admission and at least 30 days post discharge. Our main outcome was 30-day all-cause readmission. Regular physical activity was routinely assessed at the time of all outpatient visits and expressed as the total minutes of moderate or vigorous physical activity (MVPA) per week. The sample included a total of 4,596 patients (5,862 index admissions) with a mean age of 72.3 ± 11 years. The 30-day readmission rate was 18%, with 59% of readmissions occurring in the first 15 days. Multivariate adjusted analyses showed that patients reporting any level of MPVA had a significantly lower risk of 30-day readmission compared with inactive patients (1-149 min/wk of MVPA: relative risk, 0.67; 95% confidence interval, 0.55-0.81; ≥150 min/wk of MVPA: relative risk, 0.66; 95% confidence interval, 0.51-0.87). Other significant independent predictors of increased readmission included anemia, prior hospitalizations, longer lengths of stay, more comorbidities, receipt of a new oxygen prescription at discharge, use of the emergency department or observational stay before the readmission (all, P < 0.05), and being unpartnered (P = 0.08). Our findings further support the importance of physical activity in the management of COPD across the care continuum. Although it is possible that lower physical activity is a reflection of worse disease, promoting and supporting physical activity is a promising strategy to reduce the risk of readmission.

Cause-specific mortality adjudication in the UPLIFT® COPD trial: Findings and recommendations

Towards better management of COPD

Abstract: Chronic obstructive pulmonary disease (COPD) is a progressive disease and also a lead-ing cause of morbidity and mortality worldwide. The frequent readmissions of patients with COPD may reduce lung function, mental health, and quality of life; it also increases the cost of treatment and mortality rate. Some common factors that may increase the readmission frequency of COPD pa-tients include delay of diagnosis, advanced lung function decline, lack of adherence for COPD treatment, ineffective management of comorbidities, acute exacerbation or stable COPD, and infec-tions. However, these factors might be well controlled with appropriate approaches to minimize the readmission of patients with COPD. In this review, we propose a strategy with a seven-step ap-proach to reduce the readmission in COPD patients, including early diagnosis of COPD, optimal treatment for stable COPD, targeted management of comorbidities, adequate therapy for acute ex-acerbations, individualized action plans for COPD patients, effective prevention of bacterial and vi-ral infections, and adaptive program of pulmonary rehabilitation. Thus, implementing this approach may reduce the risk of readmission in patients with COPD.

RATIONALE: Quality management standards are available for chronic obstructive pulmonary disease (COPD), but how often they are followed in community settings is uncertain. OBJECTIVES: We sought to measure the adherence to standard quality of care criteria for COPD management in primary care using primary care electronic medical records as an indicator for quality of COPD management. METHODS: We conducted a cross-sectional study using EMR data from Ontario and previously validated set of COPD quality indicators previously developed by the Ontario COPD Population Health Network. We analyzed how often the COPD quality indicators were met for patients with COPD at the population-level and at the family physician-level. MEASUREMENTS AND MAIN RESULTS: Five quality indicators were assessed at population- and family physician (FP)-levels. We included 6995 patients with COPD under care of 247 FPs. The highest performing quality indicator was the recording of patients’ smoking history in the EMR. FPs varied in their rates of provision of smoking cessation support to current smokers, recording of spirometry, administration of pneumococcal and seasonal influenza vaccines. Five additional health care or medication utilization rates were assessed for all patients with COPD regardless of disease severity, including prescriptions for short-acting and long-acting bronchodilators, combined inhaled corticosteroids and long-acting bronchodilators, evidence of pulmonary rehabilitation and oxygen therapy use. CONCLUSION: EMR data can be a useful data source to study COPD care, and there are opportunities for improvement in several areas of COPD management in primary care as well as standardization of EMR use for COPD care.

Background:Studies have identified health literacy (HL) as an important determinant of asthma and chronic obstructive pulmonary disease (COPD) management. There are, however, limited data on patients' and health care professionals (HCPs') insights about the link between HL and management of asthma and COPD.Objective:The aim of this study was to elicit patients' and HCPs' perspectives with respect to factors affecting HL in the context of asthma and COPD management.Methods:A total of 16 semi-structured focus groups (10 in English and 6 in French) with patients with asthma or COPD (n = 93) and 45 interviews with HCPs, researchers, and policymakers were conducted between June 2015 and April 2017. Participants were asked to share their perspectives with respect to five predefined HL domains—accessing, understanding, evaluating, communicating, and using health-related information—in relation to disease self-management practices. Data were analyzed qualitatively, using a content analysis approach.Key Results:Most patients and HCPs reflected on factors hampering HL in relation to asthma and COPD management. Thoughts such as “not having enough time during medical consultations,” “not receiving consistent messages from different health care professionals,” and “language or cultural differences” were frequently mentioned by both patients and HCPs.Conclusions:We identified multiple factors affecting communication between patients and HCPs as it relates to the self-management of their disease. These included inconsistent messages from different providers, limited consultation time, use of technical language, failure to account for cultural differences, and reduced health literacy, especially as it related to written communication. Future interventions that aim to enhance HL skills in the context of asthma and COPD self-management should consider these issues. [HLRP: Health Literacy Research and Practice. 2021;5(3):e179–e193.]Plain Language Summary:The current study advances the health literacy (HL) knowledge base by adding patients' and health care professionals' valuable insights on factors that hamper or facilitate HL in relation to asthma and chronic obstructive pulmonary disease (COPD) management. An important insight from this study is that receiving conflicting information from different health care professional's hampers HL in patients with asthma and/or COPD.

The silent epidemic of COPD in Africa.

Chronic obstructive pulmonary disease (COPD) is one of the leading causes of morbidity and mortality in Nepal. Female community health volunteers (FCHVs) have proven effective in the delivery of reproductive, maternal, and child health services in Nepal and recently in the prevention and management of hypertension and type 2 diabetes. Evidence on their roles in COPD management is not yet available. The aim of this study was to develop, implement, and evaluate a training program for FCHVs regarding COPD prevention and management. The training program was part of a cluster-randomized trial of a 12-month intervention to improve COPD outcomes in a semi-urban area of Western Nepal. A six-day workshop consisting of thirty hours of training was developed for FCHVs. Training materials incorporated introduction to COPD, risk factors and symptoms, COPD status assessment guide for FCHVs, guidance on breathing techniques, and exercises for people living with COPD. Pre- and post-test questionnaires were administered to assess the change in knowledge of FCHVs, post training skills assessment followed by semi-structured interviews assessed FCHVs’ satisfaction with the training program. The findings of the pre- and post- test assessments showed a significant improvement in FCHVs’ COPD-related knowledge from a median (interquartile range) score of 12 (3–16) before to 21 (21–22) (p<0.001) after the training program. The qualitative assessment revealed the feasibility of FCHVs’ training on COPD and their acceptability to deliver the intervention package within the community. It also indicated that implementing future training with an extended period and a few days break in-between could enhance the effectiveness. Training of FCHVs in COPD management is feasible and leads to improvement in knowledge. The motivation shown by FCHVs to deliver the intervention could inform and guide community programs and policies for COPD prevention and management in Nepal and similar settings.

Dietary Flavonoid Intake and Incident Coronary Heart Disease in the Reasons for Geographic and Racial Differences in Stroke Study (REGARDS)

Background In Denmark, general practitioners (GPs) have the main responsibility for chronic obstructive pulmonary disease (COPD) management. Internationally, COPD appears to be significantly under-treated, which could be explained by ‘therapeutic nihilism’ or lack of knowledge. Aim To investigate: (1) To what extent COPD management provided by GPs includes the core elements of pharmacological treatment, smoking cessation and physical activity, and (2) To what extent GPs need educational support and consulting with a specialist in pulmonary medicine. Design A national cross-sectional web-based survey conducted in April–June 2019. The survey included items on COPD management and educational support needs. Setting Danish general practice. Subjects A population of approximately 3400 GPs (all GPs in Denmark). Results We received response from 470 GPs (14% response rate). Overall, the respondents reported that they offered COPD management including all relevant treatment elements. Smoking cessation was supported in 58% and physical activity was supported in 23% of the respondents. Future consultations on smoking cessation were planned by 35% and physical activity by 15% respondents. GPs responded to ‘needing educational support in COPD management’ to a ‘high degree’ in 8% and to ‘some degree’ in 43%. Conclusion The survey suggested that COPD maintenance support provided by GPs seemed to be inadequate regarding smoking cessation and physical activity. Moreover, some GPs expressed a need for educational support in COPD management. More research is needed to understand the potential barriers to evidence-based delivery of COPD-management. Key points In Denmark, general practitioners (GPs) have the main responsibility for the management of chronic obstructive pulmonary disease (COPD). The present study shows that non-pharmacological interventions such as supporting smoking cessation and particularly promoting physical activity received less attention than pharmacological treatment. The study suggests a need for educational support of the GPs in COPD management.

Educational interventions for health professionals managing chronic obstructive pulmonary disease in primary care.

Introduction