The Impact of Gastroesophageal Reflux on Hospitalization Outcomes for COPD Exacerbations: A Report of the Nationwide Inpatient Sample

Abstract

Introduction: Gastroesophageal reflux disease (GERD) has been associated with pulmonary disorders such as asthma and chronic obstructive pulmonary disease (COPD). However, the underlying pathophysiology of these associations is not clear. Microaspiration of refluxate may contribute to lung diseases, while worsening pulmonary function may also lead to increased reflux. Recent studies suggest that GERD may be associated with increased COPD exacerbations, hospitalizations, and medication use. However, the effect of reflux diagnosis on hospitalization outcomes for acute exacerbations of COPD (AECOPD) remains unclear. We aimed to evaluate the impact of GERD or reflux esophagitis on intubation rate and mortality during AECOPD hospitalization using a large, national inpatient database. Methods: This was a population-based cohort study of adult patients admitted to U.S. hospitals for AECOPD in 1998-2010 using the Nationwide Inpatient Sample database. Hospitalization outcomes assessed included rate of intubation and death. The effects of GERD or reflux esophagitis on hospitalization outcomes were evaluated by logistic regression models, adjusting for potential confounders such as age, gender, medical conditions, Charlson Comorbidity Index (CCI), disease severity, and hospital characteristics. Subgroup analysis was performed to examine the impact of reflux severity (reflux esophagitis vs GERD alone) on AECOPD outcomes. Results: 2,723,541 patients (mean age 70.2 yrs, 53% F, mean CCI 1.067) were included in the analysis, with 9,064 (70.4 yrs, 57% F, CCI 1.074) with reflux esophagitis, 335,760 (69.7 yrs, 60% F, CCI 1.014) with GERD alone, and 2,378,717 (70.3 yrs, 52% F, CCI 1.075 ) without any reflux disease. The overall intubation rate was 6.1% and mortality was 4.5%. After adjusting for potential confounders, there were independent positive associations between GERD and both intubation (OR 1.725, p < 0.0001) and death (OR 1.716, p < 0.0001). Reflux esophagitis was also independently associated with increased intubation (OR 1.739, p < 0.0001) and mortality (OR 1.724, p < 0.0001). Subgroup analyses showed no significant differences in outcomes between patients with a diagnosis of reflux esophagitis and those with GERD alone. Conclusion: A diagnosis of GERD or reflux esophagitis is independently associated with increased rate of intubation and mortality in patients hospitalized for AECOPD. Further prospective studies are needed to assess the benefit of aggressive anti-reflux therapy on AECOPD outcomes.