Hospitalization For Acute Exacerbation Of COPD Research Articles

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

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.

Thrombocytopenia as a marker of outcome in patients with acute exacerbation of chronic obstructive pulmonary disease.

Thrombocytopenia (TP) is associated with poor outcome in patients who are critically ill with pneumonia, burns, and H1N1 influenza. To our knowledge, no similar study in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) has been conducted to date. The aim of this study was to determine the impact of platelet count on the outcome of patients with AECOPD. Patients admitted to our teaching hospital for AECOPD were divided into two cohorts, those with and without TP. The outcome of all patients was followed. Of the 200 patients with AECOPD, 55 (27.5%) had TP. Of these, 14 (25.5%) died in the hospital, whereas of the 145 non-TP patents, 11 (7.5%) died (p-value = 0.001). There was a significantly higher transfer rate to the ICU and mechanical ventilation in TP patients. The mean platelet count was significantly lower in patients who died than those who were discharged (161,672 vs. 203,005 cell/μL; p-value = 0.017). There was negative correlation between duration of hospitalization and platelet count. TP was associated with poor outcome in AECOPD. TP could be considered as a marker for the assessment of inflammation and prognosis in AECOPD patients based on its cost-effective features.

Growth Differentiation Factor-15 Is a Novel Biomarker Predicting Acute Exacerbation of Chronic Obstructive Pulmonary Disease.

Exacerbations in chronic obstructive pulmonary disease (COPD) reduce quality of life and are associated with a more rapid deterioration of the disease. Growth differentiation factor-15 (GDF-15) is a novel candidate exacerbation biomarker. In this study, we aimed to assess GDF-15 as a biomarker of acute exacerbation of COPD (AE-COPD). Lung function parameters, arterial blood gas analysis, and circulating levels of GDF-15, C-reactive protein (CRP), and fibrinogen were assessed in 29 patients on admission to the hospital for AE-COPD, in 29 age-, gender-, and body mass index (BMI)-matched patients with stable COPD, and 29 matched controls with normal lung function. Patients with AE-COPD had higher circulating concentrations of GDF-15 (p < 0.001), CRP (p < 0.001), and fibrinogen (p < 0.002) compared with patients with stable COPD and healthy controls. GDF-15 levels correlated with systemic inflammatory marker CRP in patients with AE-COPD (r = 0.677, p < 0.001) and with stable COPD (r = 0.417, p = 0.024). Multivariate logistic regression analysis revealed GDF-15 (odds ratio 18.16, 95% confidence interval (CI) 2.51-134.32; p = 0.005) as an independent predictor of AE-COPD. In receiver operating characteristic analysis, GDF-15 achieved an area under the curve of 0.78 for the identification of AE-COPD. In conclusion, GDF-15 is a novel blood biomarker of AE-COPD that is more sensitive than that of CRP. GDF-15 may offer new insights into the pathogenesis of AE-COPD.

Relationship between Troponin Elevation, Cardiovascular History and Adverse Events in Patients with acute exacerbation of COPD

ABSTRACTEvidence suggests that troponin (Tn) elevation during acute exacerbation of chronic obstructive pulmonary disease (AECOPD) may predict an increase in mortality risk. We performed an observational study of 935 patients admitted to hospital for AECOPD from January 2010 to December 2012. Principal clinical and laboratory data were recorded, especially ischemic heart disease (IHD) history, Tn T values and cardiovascular drug prescription. The occurrence of all-cause death, cardiac death (CD), nonfatal myocardial infarction (MI), heart failure and cerebrovascular accident (CVA) was assessed on December 2013. Overall, 694 patients respected inclusion and exclusion criteria. We identified 210 (30%) patients without Tn elevation (negative Tn T group) and 484 (70%) patients with Tn elevation (positive Tn T group). With the exception of CVA, all adverse events were significantly higher in positive Tn T group as compared to negative Tn T group. At multivariable analysis, positive Tn T failed to predict all-cause death. Contrarily, positive Tn T emerged as independent predictors of CD (HR 1.61, 95%CI 1.2–2.2, p = 0.04), nonfatal MI (HR 3.12, 95%CI 1.4–8.1, p = 0.03) and composite endpoint including CD and nonfatal MI (HR 1.73, 95%CI 1.2–2.7, p = 0.03). Of note, positive Tn T stratified prognosis in patients without IHD history, but not in those with IHD history. In conclusion, after hospital admission for AECOPD, we observed a significant increase in the risk of cardiac adverse events in patients with Tn T elevation, especially in those without IHD history.

Viral Profile of COPD Exacerbations According to Patients.

Background : To compare the differences between elderly and non-elderly patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) due to viral infections.Methods : Patients with chronic obstructive pulmonary disease (COPD) exacerbation were recruited and classified as elderly (>65 years) and non-elderly (≤ 65 years). Sputum and oropharyngeal samples were assessed, PCR for respiratory viruses and cultures for common pathogens were performed.Results : 247 patients (median age: 69.3±9.5 years) were recruited and categorized into group A: non-elderly patients [n=81 (32.8%), median age 58±5.99] and group B: elderly patients [n=166 (67.2%), median age 74.8±4.8] years. In 133 (53.8%) patients a viral infection was identified and in 34 (13.8%) a bacterial pathogen was isolated from cultures. In 18 (7.3%) patients a double infection (bacterial+viral) was identified. In group B, the presence of cardiac failure (46.6% vs 28.3%, p<0.001), renal failure (10.5% vs 4%, p=0.03), bacterial co-infection (13.8% vs 7.4%, p=0.04), influenza vaccination rates (45.5% vs 215, p<0.001), and longer hospital stay (8.4±4.4 vs 7.5±3.2 days, p=0.02) were higher than group A. The overall rate of viral infections did not differ according to age. A trend to higher rates of infection with parainfluenza 3 [19 (20%) patients in group B vs3 (7.5%) patients in group A, p=0.04] was observed in older patients.Conclusion : No differences on the rate and type of viral infections were noted for elderly vs non elderly patients. However, they tended to have more bacterial co-infections that led to AECOPD and longer hospitalization stays compared to non-elderly patients.

C-Reactive Protein at Discharge, Diabetes Mellitus and ≥1 Hospitalization During Previous Year Predict Early Readmission in Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease

Recurrent hospitalizations in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) patients have clinical and economic consequences; particularly those readmitted soon after discharge. The aim of our observational study was to determine predictors of early readmission to hospital (30 days from discharge).Prospective data on 125 hospitalized AECOPD patients were collected over a 30-month period at two Spanish university hospitals. Based on readmission after discharge, patients were divided into non-readmitted (n = 96) and readmitted (n = 29). Measures of serum inflammatory biomarkers were recorded on admission to hospital, at day 3 and at discharge; data on clinical, laboratory, microbiological and severity features were also recorded.In a multivariate model, C-reactive protein (CRP) at discharge ≥7.6 mg/L, presence of diabetes and ≥1 hospitalization for AECOPD during previous year were significant risk factors for predicting readmission. Presence of all 3 risk factors perfectly identified the readmitted patients (positive and negative predictive values of 1.000; 95% CI, 1.00–1.00).A combination of 3 readily available clinical and biochemical parameters is accurate in identifying hospitalized AECOPD patients at risk for early readmission.

Serum uric acid as a predictor of mortality and future exacerbations of COPD

Serum uric acid is increased in respiratory disease, especially in the presence of hypoxia and systemic inflammation. We evaluated serum uric acid as a biomarker for prediction of mortality and future acute exacerbation of chronic obstructive pulmonary disease (AECOPD). Serum uric acid was measured in 314 eligible consecutive patients on admission for AECOPD. Patients were evaluated monthly for 1 year. Uric acid levels were higher in patients with more severe airflow limitation and in those experiencing frequent exacerbations. High uric acid levels (≥6.9 mg·dL(-1)) were an independent predictor of 30-day mortality in multivariate Cox regression analysis (HR 1.317, 95% CI 1.011-1.736; p=0.044), but not of 1-year mortality. Patients with high serum uric acid required more prolonged hospitalisation, and more often needed noninvasive ventilation and admission to the intensive care unit within 30 days. In addition, high uric acid levels were associated with increased risk and hospitalisation for AECOPD in 1 year in multivariate Poisson regression analysis (incidence rate ratio 1.184 (95% CI 1.125-1.246) and 1.190 (95% CI 1.105-1.282), respectively; both p<0.001). Serum uric acid is associated with increased 30-day mortality and risk for AECOPD and hospitalisations in 1-year follow-up. This low-cost biomarker may be useful in the identification of high-risk chronic obstructive pulmonary disease patients that could benefit from intensive management.

Trends in hospital admissions for acute exacerbation of COPD in Spain from 2006 to 2010

We aim to analyze changes in incidence, comorbidity profile, length of hospital stay (LOHS), costs and in-hospital mortality (IHM) of patients hospitalized for acute exacerbations of chronic obstructive pulmonary disease (AE-COPD) over a 5-year study period in Spain. We selected all hospital admissions for AE-COPD between 2006 and 2010 from the National Hospital Discharge Database covering the entire population of Spain. We identified a total of 215,835 patients. Overall crude incidence had decreased from 2.9 to 2.4 exacerbations of COPD per 10,000 inhabitants from 2006 to 2010 (p < 0.001). In 2006, 17.9% of patients had a Charlson Index >2 and in 2010, the prevalence had increased to 25.0% (p < 0.001). Regarding to treatment, we detected a significant increase in the use of non-invasive ventilation from 2.1% in 2006 to 5.3% in 2010 (p < 0.001). The median LOHS was 7 days in 2006 and it remained stable until 2010. During the period studied, the mean cost per patient increased from 3747 to 4129 Euros. Multivariate analysis showed that incidence of hospitalizations for AE-COPD and IHM had significantly decreased from 2006 to 2010. The current study provides data indicating a decrease in incidence of hospital admissions for AE-COPD in Spain from 2006 to 2010 with concomitant reduction in IHM, despite increasing comorbidity during this period, with no variations in LOHS. The mean cost per patient has risen significantly.

Predictors of 1-Year Mortality at Hospital Admission for Acute Exacerbations of Chronic Obstructive Pulmonary Disease

Background: Acute exacerbations of chronic obstructive pulmonary disease (AE-COPD) are related to high mortality, especially in hospitalized patients. Predictors for severe outcomes are still not sufficiently defined. Objectives: To assess the mortality rate and identify potential determinants of mortality in a cohort of patients hospitalized for AE-COPD. Methods: A retrospective, observational cohort study including all consecutive patients admitted between January 1, 2009, and April 1, 2010, for AE-COPD. Potential predictors were assessed at initial presentation at the emergency room. The primary outcome was mortality during 1-year follow-up. Univariate and multivariate time-to-event analyses using Cox proportional hazard models were employed for statistical analysis. Results: A total of 260 patients were enrolled in this study. Mean age was 70.5 ± 10.8 years, 50.0% were male and 63.4% had severe COPD. The in-hospital mortality rate was 5.8% and the 1-year mortality rate was 27.7%. Independent risk factors for mortality were age [hazard ratio (HR) = 1.04; 95% confidence interval (CI) = 1.01–1.07], male sex (HR = 2.00; 95% CI = 1.15–3.48), prior hospitalization for AE-COPD in the last 2 years (HR = 2.56; 95% CI = 1.52–4.30), prior recorded congestive heart failure (HR = 1.75; 95% CI = 1.03–2.97), Pa<smlcap>c</smlcap><smlcap>o</smlcap>₂ ≥6.0 kPa (HR = 2.90; 95% CI = 1.65–5.09) and urea ≥8.0 mmol/l (HR = 2.38; 95% CI = 1.42–3.99) at admission. Conclusions: Age, male sex, prior hospitalization for AE-COPD in the last 2 years, prior recorded congestive heart failure, hypercapnia and elevated levels of urea at hospital admission are independent predictors of mortality within the first year after admission.

Acute Exacerbations of COPD in the United States: Inpatient Burden and Predictors of Costs and Mortality

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are a leading cause of hospitalizations in the United States and the major cost driver of COPD. This study determined the national inpatient burden of AECOPD and assessed the association of co-morbidities and hospital characteristics with inpatient costs and mortality. Discharge records from the Agency for Healthcare Research and Quality (AHRQ) Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample for 2006 was utilized. Outcomes of costs and mortality were assessed for AECOPD hospitalizations in cases ≥40 years of age. Multivariate regression analyses using a generalized linear model framework were conducted to determine predictors of inpatient costs and mortality controlling for patient demographics, primary payer, co-morbidity index, length of stay, hospital region, mechanical ventilation, and admission period. Overall, 1,254,703 hospitalizations for AECOPD were observed with mean costs of $9545(±12,700) and total costs of $11.9 billion. In-hospital mortality was 4.3% (N = 53,748). Discharges averaged 70.6 (±11.9) years of age. The majority were female (52.8%) and of white race (83.6% of reported race). Several co-morbidities were significantly associated with both costs and mortality (p < 0.001): acute myocardial infarction; congestive heart failure; cerebrovascular disease; lung cancer; cardiac arrhythmias; pulmonary circulation disorders; and weight loss. Significantly higher costs (p < 0.001) were associated with large and urban hospitals. The importance of co-morbidities in AECOPD is indicated in their association with prognosis and inpatient costs. Future research should determine if better management of these conditions can favorably impact the COPD disease burden.

The Validity of International Classification of Diseases, Ninth Revision, Clinical Modification Diagnosis Codes for Identifying Patients Hospitalized for COPD Exacerbations

Acute exacerbations of COPD (AE-COPD) are a leading cause of hospitalizations in the United States. To estimate the burden of disease (eg, prevalence and cost), identify opportunities to improve care quality (eg, performance measures), and conduct observational comparative effectiveness research studies, various algorithms based on the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes have been used to identify patients with COPD. However, the validity of these algorithms remains unclear. We compared the test characteristics (sensitivity, specificity, positive predictive value, and negative predictive value) of four different coding algorithms for identifying patients hospitalized for an exacerbation of COPD with chart review (reference standard) using a stratified probability sample of 200 hospitalizations at two urban academic medical centers. Sampling weights were used when calculating prevalence and test characteristics. The prevalence of COPD exacerbations (based on the reference standard) was 7.9% of all hospitalizations. The sensitivity of all ICD-9-CM algorithms was very low and varied by algorithm (12%-25%), but the negative predictive value was similarly high across algorithms (93%-94%). The specificity was > 99% for all algorithms, but the positive predictive value varied by algorithm (81%-97%). Algorithms based on ICD-9-CM codes will undercount hospitalizations for AE-COPD, and as many as one in five patients identified by these algorithms may be misidentified as having a COPD exacerbation. These findings suggest that relying on ICD-9-CM codes alone to identify patients hospitalized for AE-COPD may be problematic.

The burden of illness in patients with moderate to severe chronic obstructive pulmonary disease in Canada.

No recent Canadian studies with physician- and spirometry-confirmed diagnosis of chronic obstructive pulmonary disease (COPD) that assessed the burden of COPD have been published. To assess the costs associated with maintenance therapy and treatment for acute exacerbations of COPD (AECOPD) over a one-year period. Respirologists, internists and family practitioners from across Canada enrolled patients with an established diagnosis of moderate to severe COPD (Global initiative for chonic Obstructive Lung Disease stages 2 and 3) confirmed by postbronchodilator spirometry. Patient information and health care resources related to COPD maintenance and physician-documented AECOPD over the previous year were obtained by chart review and patient survey. A total of 285 patients (59.3% male; mean age 70.4 years; mean pack years smoked 45.6; mean duration of COPD 8.2 years; mean postbronchodilator forced expiratory volume in 1 s 58.0% predicted) were enrolled at 23 sites across Canada. The average annual COPD-related cost per patient was $4,147. Across all 285 patients, maintenance costs were $2,475 per patient, of which medications accounted for 71%. AECOPD treatment costs were $1,673 per patient, of which hospitalizations accounted for 82%. Ninety-eight patients (34%) experienced a total of 157 AECOPD. Treatment of these AECOPD included medications and outpatient care, 19 emergency room visits and 40 hospitalizations (mean length of stay 8.9 days). The mean cost per AECOPD was $3,036. The current costs associated with moderate and severe COPD are considerable and will increase in the future. Appropriate use of medications and strategies to prevent hospitalizations for AECOPD may reduce COPD-related costs because these were the major cost drivers.

Effect of early pulmonary rehabilitation on health care utilization and health status in patients hospitalized with acute exacerbations of COPD

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) incur heavy utilization of health-care resources for patients who require hospitalization. We evaluated whether an early outpatient pulmonary rehabilitation programme (PRP) after hospitalization for AECOPD could reduce acute health-care utilization over the succeeding year. Sixty patients admitted with AECOPD were randomized to either PRP or usual care (UC). The PRP group received 8weeks of outpatient rehabilitation programme 2-3weeks after discharge from hospital. Lung function, 6min walk test and dyspnoea score were assessed at baseline, 3, 6, 9 and 12months, while St George's respiratory questionnaire and cardiopulmonary exercise test were assessed at baseline, 3, 6 and 12months. The PRP and UC groups demonstrated a 53.3% and 43.3% risk of readmissions at 12months (incident risk ratio 0.97 (95% CI: 0.57-1.60), P=0.90). The mean readmission rates were 1.00±1.20 and 1.03±1.87 (P=0.47) for the PRP versus UC groups respectively. The rates of AECOPD and emergency department visits were similar between the two groups. The St George's respiratory questionnaire total score was lower in the PRP group (40.15±19.10 vs 46.91±18.21, P=0.01 and 42.3±20.06 vs 51.44±18.98 P=0.01 at 3 and 6months respectively). There were no statistically significant differences in the FEV(1) % predicted, dyspnoea score, 6min walk test and maximal oxygen consumption during exercise test between PRP and UC at different time points. An early rehabilitation programme following AECOPD led to improvement in quality of life up to 6months, but did not reduce health-care utilization at 1year.

Hospitalizations for Acute Exacerbations of Chronic Obstructive Pulmonary Disease: How You Count Matters

ABSTRACTICD-9-CM diagnosis codes are increasingly used to estimate the burden of disease, as well as to evaluate the quality of care and outcomes of various conditions. Acute exacerbations of COPD (AE-COPD) are common and associated with substantial health and financial burden in the U.S. Whether published algorithms that employ different combinations of ICD-9-CM codes to identify patients hospitalized for AE-COPD yield similar or different estimates of disease burden is unclear. In this study, the Nationwide Inpatient Sample from years 2000–2006 was used to identify and compare the number of hospitalizations, healthcare utilization, and outcomes for patients hospitalized for AE-COPD in the U.S. AE-COPD was identified using five different published ICD-9-CM algorithms. Estimates of the annual number of hospitalizations for AE-COPD in the U.S. varied more than 2-fold (e.g., 421,000 to 870,000 in 2006). Outcomes and healthcare utilization of patients hospitalized for AE-COPD varied substantially, depending on the algorithm used (e.g., in-hospital mortality 2.0% to 5.1%, total hospital days 2.0 to 5.1 million in 2006). Observed trends in the number of hospitalizations over the 7-year period varied depending on which algorithm was used. In conclusion, the estimated health burden and trends in hospitalizations for AE-COPD in the United States differ, depending on which ICD-9-CM algorithm is used. To improve our understanding of the burden of AE-COPD and to ensure that quality of care initiatives are not misdirected, a validated approach to identifying patients hospitalized for AE-COPD is needed.