Chronic Obstructive Pulmonary Disease Hospitalizations Research Articles

Does ambient CO have protective effect for COPD patient?

BackgroundExisting studies found paradoxical effects of carbon monoxide (CO) on human health. Carbon monoxide (CO), at high concentrations, is a well-known toxicant, but recent studies suggest that CO at low concentrations may have protective health effects under certain conditions. ObjectivesTo investigate the acute effect of ambient CO on hospital admission for chronic obstructive pulmonary disease (COPD) in Shanghai, China. MethodsDaily data on COPD admissions and CO concentrations between 2006 and 2008 were collected. We applied over-dispersed generalized additive Poisson models, adjusted for weather conditions, day of the week and public holidays, long-term and seasonal trends. ResultsDuring the study period, the average CO concentration was 1.3mg/m3, well below the international health-based standard. Negative associations were found between ambient CO concentration and daily COPD hospitalization. An interquartile range increase (0.6mg/m3) in CO concentration at lag 3day corresponded to −2.97% (95% confidence interval: −4.63%, −1.31%) change in COPD hospitalization. The negative associations were robust after adjustment for co-pollutants (PM10, NO2 and SO2). The protective effect of CO appeared to be more evident in the cool season. ConclusionShort-term exposure to CO at low ambient concentration may be associated with reduced risk of COPD hospitalization. Our results may contribute to a comprehensive understanding on the health effects of ambient CO.

Comorbidity associated with referral to pulmonary rehabilitation in people hospitalized with chronic obstructive pulmonary disease.

Comorbid conditions are common in people with chronic obstructive pulmonary disease (COPD) and may affect therapeutic management. The aim of this study was to examine the association of comorbidity in people with COPD with referral to a pulmonary rehabilitation (PR) program. An analysis of data was conducted from an observational study of 88 people admitted to hospital with a primary diagnosis of COPD. Demographic and admission-related data were extracted and comorbidity scores (Charlson and Rx-Risk-V) were calculated. Total comorbidity scores were not associated with referral to PR; however specific comorbid conditions were. The presence of anxiety (from medical records) was more frequent in those referred to PR (χ = 4.20; P = .04; OR, 7.0; 95% CI, 0.8-59.0). The presence of hypertension (as determined by Rx-Risk-V) was more likely to result in PR referral (χ = 6.69; P = .01; OR, 6.8; 95% CI, 1.6-29.1), and, in those with arrhythmia, PR referral was less likely (χ = 4.22; P = .04; OR, 0.28; 95% CI, 0.08-0.99). Patients who had been referred to PR had lower forced expiratory volume in 1 second (FEV1 percent predicted) (P < .001) and greater hospital bed days in previous 3 years (P = .051). In a multivariate analysis, FEV1 percent predicted, bed days in the last 3 years, and Rx-Risk-V categories of hypertension and arrhythmia accounted for 25% of variance in referral to PR. In addition to COPD disease severity and hospital utilization, specific comorbidities identified with a comprehensive system (ie, the Rx-Risk score) were associated with referral to PR in this sample.

Hospitalisation for chronic obstructive pulmonary disease and risk of suicide: a population-based case–control study

ObjectivesTo examine risk of suicide among individuals with hospitalised chronic obstructive pulmonary disease (COPD) and to profile differences according to sex, age, psychiatric history, and recency and frequency of COPD...

Gastroesophageal Reflux Disease and Length of Hospitalization in Patients With Chronic Obstructive Pulmonary Disease: A Retrospective Observational Study

Introduction: The association between gastroesophageal reflux disease (GERD) and chronic obstructive pulmonary disease (COPD) has been well described in the literature. Previous studies have even shown there to be a correlation between the severity of reflux symptoms with the risk of COPD exacerbation and hospitalization. The purpose of this study was to investigate whether the presence of GERD affected the risk of prolonged hospitalization among patients carrying a diagnosis of COPD. Methods: This is a retrospective observational cohort study involving COPD patients admitted to hospital during the study period (2008-2012) with COPD exacerbations identified through the ICD-9 codes. Patient demographics, comorbidities, pulmonary function tests, in-hospital events, and re-admissions were retrieved through the review of the electronic medical records. Our primary variable of interest in this study was the GERD and the studied primary outcome was the length of stay during the index hospitalization. Results: Our study population consisted of 301 patients; 225 patients without GERD and 76 patients with GERD. Baseline characteristics of the study population were compared between patients with GERD and without GERD. The statistically different baseline characteristics between-groups included smoking status (42.7% in non-GERD vs 30.3%); BMI (30.1 kG/M2 in GERD vs 27.8), and PPI use (57.9% in GERD vs 25.8%). In univariate linear regression analysis, GERD patients were noticed to have lower relative risk of the hospital stay (RR: 0.26, p=0.02). In the multivariate regression analysis for length of stay adjusted for age, sex, race, BMI, smoking, GOLD stages, PPI use, and Charlson comorbidity index, relative risk for GERD vs non-GERD was 0.28 (p=0.02), GOLD stages III&IV vs I&II was 3.16 (p=0.02), and comorbidity index was 1.56 (p=0.01). Conclusion: Among patients with COPD, GERD was not shown to increase length of stay during index hospitalization after adjusted for included risk factors. Paradoxically, GERD patients had lower risk of a prolonged hospitalization. As expected, patients with greater COPD severity had a statistically significant longer length of stay. More investigation is required to understand why patients with GERD had relatively shorter hospitalizations.

Combination long-acting β-agonists and inhaled corticosteroids compared with long-acting β-agonists alone in older adults with chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease (COPD), a manageable respiratory condition, is the third leading cause of death worldwide. Knowing which prescription medications are the most effective in improving health outcomes for people with COPD is essential to maximizing health outcomes. To estimate the long-term benefits of combination long-acting β-agonists (LABAs) and inhaled corticosteroids compared with LABAs alone in a real-world setting. Population-based, longitudinal cohort study conducted in Ontario, Canada, from 2003 to 2011. All individuals aged 66 years or older who met a validated case definition of COPD on the basis of health administrative data were included. After propensity score matching, there were 8712 new users of LABA-inhaled corticosteroid combination therapy and 3160 new users of LABAs alone who were followed up for median times of 2.7 years and 2.5 years, respectively. Newly prescribed combination LABAs and inhaled corticosteroids or LABAs alone. Composite outcome of death and COPD hospitalization. The main outcome was observed among 5594 new users of LABAs and inhaled corticosteroids (3174 deaths [36.4%]; 2420 COPD hospitalizations [27.8%]) and 2129 new users of LABAs alone (1179 deaths [37.3%]; 950 COPD hospitalizations [30.1%]). New use of LABAs and inhaled corticosteroids was associated with a modestly reduced risk of death or COPD hospitalization compared with new use of LABAs alone (difference in composite outcome at 5 years, -3.7%; 95% CI, -5.7% to -1.7%; hazard ratio [HR], 0.92; 95% CI, 0.88-0.96). The greatest difference was among COPD patients with a codiagnosis of asthma (difference in composite at 5 years, -6.5%; 95% CI, -10.3% to -2.7%; HR, 0.84; 95% CI, 0.77-0.91) and those who were not receiving inhaled long-acting anticholinergic medication (difference in composite at 5 years, -8.4%; 95% CI, -11.9% to -4.9%; HR, 0.79; 95% CI, 0.73-0.86). Among older adults with COPD, particularly those with asthma and those not receiving a long-acting anticholinergic medication, newly prescribed LABA and inhaled corticosteroid combination therapy, compared with newly prescribed LABAs alone, was associated with a significantly lower risk of the composite outcome of death or COPD hospitalization.

Treating COPD in the Real World

Evidence-basedmedicine is central tomodernmedical practice and relies on the availability of data from appropriately conducted randomized clinical trials (RCTs). These studies establish whether treatment is effective and, when an active comparator group is included in the trial,whether the new therapy is better than currently used treatment. In some conditions such as chronic obstructive pulmonary disease (COPD) for which no single surrogate end point predicts response to treatment, multiple trials of varying duration are neededtoconvincephysiciansandregulators thatdrugtherapy is beneficial. Themainstays of COPDmanagement, including inhaled long-acting antimuscarinic agents or long-acting β-agonists (LABAs) alone or combined with inhaled corticosteroids (ICSs),havebeenshown inRCTs to improve lung function and quality of life and reduce exacerbation frequency.1-3 Patients included in these trials are selectedonthebasisofhaving stable COPD without serious diseases that would lead to prematuredeath, and these studies are then incorporated into treatment guidelines that direct clinical practice.4 AlthoughRCTsprovideevidence thatadrugworks inaspecificpatientpopulation,whathappenswhen treatment isused in the general patient population seen in daily practice remains uncertain. Evidence from RCTs may be biased due to premature study withdrawal, which limits the ability of investigators to answer important supplementary questions about the effects of treatment on the natural history of the disease.5 Large clinical trials can identify unanticipated new adverse effects such as pneumonia with ICS use,6 although whether the newevents have the same clinical importance as non–steroid-associated pneumonia is less clear.7,8 More importantly, theprofile ofpatients included inRCTsdiffers in age and comorbidity from that of many patients with COPD who are seenbyphysicians inmost settings.Hence, it is important to establishwhether outcomes seen in clinical treatment trials apply in the so-called real world of clinical practice. Large administrative health care databases, statistical methods needed to interrogate these complex data sets, and, in somecountries likeCanada, comprehensivehealthcareprovision that reduces confounding due to socioeconomic treatment choices all provide the opportunity to study the effect ofclinicians’prescribingchoices. In this issueofJAMA,Gershon and colleagues9 report the results of an investigation of the comparative efficacy of using a LABA alone or together with an ICS in elderly patients with COPD living in Ontario. The authors identified patient records for 38 266 individuals who met their database-validated diagnosis of COPD and had received a newprescription for a LABAor a LABA-ICS combination.Approximately 1 in 10patients receivedaLABAasamonotherapy, possibly reflecting the influence of guidelines and pharmaceuticalpromotionontreatmentchoices.Patientswere matched for confounding variables using a propensitymatching protocol, and the resulting 3160 LABA and 8712 LABA-ICS users were followed up for as long as 5 years, with theprincipal outcomebeing riskofdeathorhospitalization for COPD. The matched patients were older (mean age, 77 years) and had more comorbid diseases (median, 7) than is usual in RCT populations. Approximately 30% had been hospitalized in the previous 6 months and 28% had a diagnosis of asthma recordedat some timepreviously.Approximately 25%hadnot undergone spirometry to confirm theCOPDdiagnosis, but the demographic characteristics of this subgroup and its subsequent outcomes were similar to the group as a whole. Median life expectancy in these older patients was approximately 2.5 years, leading to an annual mortality rate almost3 timeshigher thanwasseen in theTORCHstudy, theonly RCT to studymortality with ICS-LABA therapy as its primary endpoint.1 In the studybyGershonet al,9 amongpatients prescribed ICS-LABAdrugs, the relative risk of death or hospitalization was approximately 8% less than among those treated withLABAsalone.This is similar to the6.8%reduction in relative riskofdeathreportedwith thesedrugs in theTORCHstudy, although that difference in the latter study was not statistically significant. This resultmay reflect the greater number of deaths reported in the study by Gershon et al compared with the TORCH study (4353 vs 398, respectively) and the use of a combined end point with COPD hospitalizations. As Gershon et al report, the benefit associated with ICS-LABA use was greatest among patients with a prior diagnosisofasthmaandamongpatientswithout thisdiagnosiswho did not receive a long-acting antimuscarinic agent. However, there was no difference between treatments in the incidence of pneumonia. This is in contrast bothwith previousRCTs2,6,7 and with a large database study from Quebec10 that reported adoublingof the incidenceofpneumonia inCOPDpatients receiving ICSs. However, the population in the study by Gershonet alwasdefineddifferently, had adifferent baseline risk profile forpneumonia, andwas followedup for longer than the 60 days reported in the Quebec study. Database studies always raise concerns about why a physician prescribed a particular drug for a specific patient, often leading to important differences between study groups. The size and scope of the report byGershon et al provide some reassurance that this is not themain factor in explaining thedifferences they report. Their diagnostic criterion identified approximately 80%of patients correctly as havingCOPD, and in a series ofmodeled scenarioswith increasing degrees of diagRelated article page 1114 Opinion

Effect of exposure to O₃ , NO₂, and SO₂ on chronic obstructive pulmonary disease hospitalizations in Tabriz, Iran.

Air pollution in cities is a serious environmental problem especially in the developing countries. We examined the associations between gaseous pollutants and hospitalizations for chronic obstructive pulmonary diseases (COPD) among people living in Tabriz, a city in north western of Iran. We used the approach proposed by the World Health Organization (WHO) using the AirQ 2.2.3 software developed by the WHO European Center for Environment and Health, Bilthoven Division. To assess human exposure and health effect, data were used for ozone as a1h average; for nitrogen dioxide and sulfur dioxide as daily average concentrations. The association between air pollution and chronic obstructive pulmonary disease (COPD) was assessed using AirQ 2.2.3 model. The results of this study showed that 3 % (95 % CI 1.2-4.8 %) of HA COPD were attributed to O3 concentrations over 10 μg/m(3). Also, 0.9 % (95 % CI 0.1-2.2 %) and 0.4 % (95 % CI 0-1.1 %) of HA COPD were attributed to NO2 and SO2 concentrations over 10 μg/m(3), respectively. For every 10 μg/m(3) increase in O3, NO2, and SO2 concentrations, the risk of HA COPD increase to about 0.58, 0.38, and 0.44 %, respectively. We found significant positive associations between the levels of all air pollution and hospital admissions COPD. Otherwise, O3, NO2, and SO2 have a significant impact on COPD hospitalization.

Long-term exposure to outdoor air pollution and the incidence of chronic obstructive pulmonary disease in a national English cohort

ObjectivesThe role of outdoor air pollution in the incidence of chronic obstructive pulmonary disease (COPD) remains unclear. We investigated this question using a large, nationally representative cohort based on primary...

Psychosocial Risk Factors for Hospitalisation and Death from Chronic Obstructive Pulmonary Disease: A Prospective Cohort Study

Only a few smaller studies have addressed the effect of psychosocial factors on risk of chronic obstructive pulmonary disease (COPD) in spite of the potential for psychosocial stress to affect development of the disease through immunological and behavioural pathways. The aim of this study is to determine the relation between various psychosocial risk factors, individually and accumulated, and COPD hospitalisation and deaths. A total of 8728 women and men free of asthma and COPD participating in the Copenhagen City Heart Study, were asked comprehensive questions on major life events, work-related stress, social network, vital exhaustion, economic hardship, and sleep medication in 1991–1993 and followed in nationwide registers until 2009, with <2% loss to follow-up. During follow-up, 461 women and 352 men were hospitalized with or died from COPD. Major life events in adult life and vital exhaustion were both associated with a higher risk of COPD in an exposure-dependent manner, with high vital exhaustion being associated with a hazard ratio [HR] of 2.31 (95% CI 1.69–3.16) for women and 2.48 (1.69–3.64) for men. A higher risk of COPD was also found in participants who experienced economic hardship or had a dysfunctional social network. Furthermore, the accumulation of psychosocial risk factors was associated with a higher risk of COPD in both women (HR = 2.40, 1.78–3.22) and men (HR = 1.93, 1.33–2.80). Psychosocial vulnerability may be important to consider both in clinical practice and when planning future preventive strategies against COPD.

Respiratory Pharmacotherapy Use in Patients Newly Diagnosed with Chronic Obstructive Pulmonary Disease in a Primary Care Setting in the UK: A Retrospective Cohort Study

This retrospective cohort study aimed to analyze the prescribing practices of general practitioners treating patients with newly diagnosed chronic obstructive pulmonary disease (COPD), and to assess characteristics associated with initial pharmacotherapy. Patients were identified in the General Practice Research Database, a population-based UK electronic medical record (EMR) with data from January 1, 2008 to December 31, 2009. Patient characteristics, prescribed COPD pharmacotherapies (≤12 months before diagnosis and within 3 months following diagnosis), co-morbidities, hospitalizations, and events indicative of a possible COPD exacerbation (≤12 months before diagnosis) were analyzed in 7881 patients with newly diagnosed COPD. Most patients (64.4%) were prescribed COPD pharmacotherapy in the 12 months before diagnosis. Following diagnosis, COPD pharmacotherapy was prescribed within 3 months in 85.0% of patients. Short-acting bronchodilators alone (22.9%) or inhaled corticosteroids + long-acting beta-2 agonists (ICS+LABA, 22.1%) were prescribed most frequently. Compared with other pharmacotherapies, the prevalence of severe airflow limitation was highest in patients prescribed ICS+LABA+long-acting muscarinic antagonists (LAMA). Moderate-to-severe dyspnea was identified most frequently in patients prescribed a LAMA-containing regimen. Patients prescribed an ICS-containing regimen had a higher prevalence of asthma or possible exacerbations recorded in the EMR than those not prescribed ICS. In conclusion, pharmacotherapy prescribed at initial COPD diagnosis varied by disease severity indicators as assessed by airflow limitation, dyspnea, history of asthma, and possible exacerbations. Frequent prescription of COPD pharmacotherapies before the first-recorded COPD diagnosis indicates a delay between obstructive lung disease presentation in primary care practice and assignment of a medical diagnosis.

Improvement in COPD management by access to asthma/COPD clinics in primary care: Data from the observational PATHOS study

Chronic obstructive pulmonary disease (COPD) guidelines emphasize the importance of patient education to improve quality of life and avoid exacerbations. Longitudinal evaluations of structured management of COPD in primary care are lacking. To evaluate the impact of primary care asthma/COPD clinics on exacerbations, hospitalizations, and associated costs in COPD. This population-based, retrospective, observational study, linking primary care medical records data to mandatory Swedish national registries, included patients with COPD from 76 primary healthcare centers (1999-2009). A questionnaire on access to an asthma/COPD clinic was retrospectively answered. Propensity score matching was performed at index (COPD diagnosis) by center type (with and without an asthma/COPD clinic). Poisson regression was used to compare the yearly rate of exacerbations (hospitalization, emergency visits, or prescription for oral steroids or antibiotics) and COPD-related prescriptions at the centers. An economic analysis was performed from the Swedish healthcare perspective using 2011 unit costs and the incremental cost-effectiveness ratio was calculated. The study included 21,361 patients (mean age, 68.0 years; 53% female). Access to asthma/COPD clinics increased from 34% to 85% during the study period. Patients at primary healthcare centers with asthma/COPD clinics had 27% fewer exacerbations (0.71 vs. 0.98) and 37% fewer hospitalizations annually (0.36 vs. 0.58) (p<0.0001). Asthma/COPD clinics reduced the annual cost of medication and healthcare contacts by 37% (SEK 52,892 [€5858] to SEK 33,410 [€3700] per patient). Patients at primary healthcare centers with asthma/COPD clinics experienced fewer COPD exacerbations and hospitalizations, and overall treatment costs were substantially reduced. ClinicalTrials.gov identifier: NCT01146392.

Simvastatin for the Prevention of Exacerbations in Moderate-to-Severe COPD

BackgroundRetrospective studies have shown that statins decrease the rate and severity of exacerbations, the rate of hospitalization, and mortality in chronic obstructive pulmonary disease (COPD). We prospectively studied the efficacy of simvastatin in preventing exacerbations in a large, multicenter, randomized trial.MethodsWe designed the Prospective Randomized Placebo-Controlled Trial of Simvastatin in the Prevention of COPD Exacerbations (STATCOPE) as a randomized, controlled trial of simvastatin (at a daily dose of 40 mg) versus placebo, with annual exacerbation rates as the primary outcome. Patients were eligible if they were 40 to 80 years of age, had COPD (defined by a forced expiratory volume in 1 second [FEV1] of less than 80% and a ratio of FEV1 to forced vital capacity of less than 70%), and had a smoking history of 10 or more pack-years, were receiving supplemental oxygen or treatment with glucocorticoids or antibiotic agents, or had had an emergency department visit or hospitalization for COPD within the past year. Patients with diabetes or cardiovascular disease and those who were taking statins or who required statins on the basis of Adult Treatment Panel III criteria were excluded. Participants were treated from 12 to 36 months at 45 centers.ResultsA total of 885 participants with COPD were enrolled for approximately 641 days; 44% of the patients were women. The patients had a mean (±SD) age of 62.2±8.4 years, an FEV1 that was 41.6±17.7% of the predicted value, and a smoking history of 50.6±27.4 pack-years. At the time of study closeout, the low-density lipoprotein cholesterol levels were lower in the simvastatin-treated patients than in those who received placebo. The mean number of exacerbations per person-year was similar in the simvastatin and placebo groups: 1.36±1.61 exacerbations and 1.39±1.73 exacerbations, respectively (P=0.54). The median number of days to the first exacerbation was also similar: 223 days (95% confidence interval [CI], 195 to 275) and 231 days (95% CI, 193 to 303), respectively (P=0.34). The number of nonfatal serious adverse events per person-year was similar, as well: 0.63 events with simvastatin and 0.62 events with placebo. There were 30 deaths in the placebo group and 28 in the simvastatin group (P=0.89).ConclusionsSimvastatin at a daily dose of 40 mg did not affect exacerbation rates or the time to a first exacerbation in patients with COPD who were at high risk for exacerbations. (Funded by the National Heart, Lung, and Blood Institute and the Canadian Institutes of Health Research; STATCOPE ClinicalTrials.gov number, NCT01061671.)

Chronic obstructive pulmonary disease hospital admissions and drugs--unexpected positive associations: a retrospective general practice cohort study.

Background:Increased prescribing of inhaled long-acting anti-muscarinic (LAMA) and combined inhaled long-acting β2-agonist and corticosteroid (LABA+ICS) drugs for the treatment of chronic obstructive pulmonary disease (COPD) has led to hopes of reduced hospital admissions from this disease.Aims:To investigate the impact of rising primary care prescribing of LAMA and LABA+ICS drugs on COPD admissions.Methods:This retrospective cohort study of general practice COPD admission and prescribing data between 2007 and 2010 comprised a representative group of 806 English general practices (population 5,264,506). Outcome measures were practice rates of COPD patient admissions and prescription costs of LAMA and LABA+ICS. General practice characteristics were based on the UK quality and outcomes framework.Results:Rates of COPD admissions remained stable from 2001 to 2010. Practice-prescribing volumes of LAMA per practice patient and LABA+ICS per practice patient increased by 61 and 26%, respectively, between 2007 and 2010. Correlation between costs of LAMA and those of LABA+ICS increased year on year, and was the highest in 2010 (Pearson’s r=0.68; 95% confidence interval (CI), 0.64–0.72). Practice COPD admission rates were positively predicted by practice-prescribing volumes of LAMA (2010: B=1.23, 95% CI, 0.61–1.85) and of LABA+ICS (2010: B=0.32, 95% CI, 0.12–0.52) when controlling for practice list size, COPD prevalence and deprivation.Conclusion:The increase in the prescribing of LAMA and LABA+ICS inhalers was not associated with the predicted fall in hospital admission rates for COPD patients. The positive correlation between high practice COPD prescribing and high practice COPD admissions was not explained.

Friday and weekend hospital stays: effects on mortality.

While weekend hospital admissions are associated with higher mortality, the effects of weekend hospital stays are not known. We assessed whether patients hospitalised for chronic obstructive pulmonary disease (COPD) or pneumonia have higher mortality during weekend and Friday stays. Our cohort consisted of all hospitalisations for COPD or pneumonia during 1990-2007 from the healthcare databases of the province of Quebec, Canada. The hazard ratio (HR) of in-patient death associated with Friday and weekend stay was estimated by the Cox model with time-dependent covariates, adjusted for age, sex and comorbidity. The cohort included 323 895 hospitalisations for COPD or pneumonia during which 32 414 deaths occurred (rate of death 8.06 per 1000 per day). Mortality was higher for weekend (HR 1.06, 95% CI 1.03-1.09) but not Friday admissions (HR 0.97, 95% CI 0.95-1.00), relative to Monday-Thursday admissions. Independently of the admission day, mortality was higher during weekend stays (HR 1.07, 95% CI 1.04-1.09) and Friday stays (HR 1.05, 95% CI 1.02-1.08), relative to Monday-Thursday stays. Patients hospitalised for COPD or pneumonia are at increased risk of death when staying over on a Friday or a weekend. The additional 40-56 deaths per 100 000 patients staying in hospital on those days are most likely due to reduced access to healthcare at that time.

Antibiotic prophylaxis in COPD: Why, when, and for whom?

One of the main goals of treatment of chronic obstructive pulmonary disease (COPD) is the prevention of exacerbations. Bronchodilators and anti-inflammatories are the first line therapy for treatment of COPD; however, these drugs are not effective in suppressing all infective exacerbations. In fact, the use of inhaled corticosteroids in patients with COPD and chronic bronchial infection may even increase the bacterial load in the airways and increase the risk of pneumonia.In this context, the use of long-term or intermittent antibiotic treatment has shown to prevent COPD exacerbations and hospitalizations. These effects may be achieved by reducing bacterial load in the airways in stable state and/or bronchial inflammation. The drugs more extensively studied are macrolides, followed by quinolones. The long-term use of antibiotics is associated with an increased risk of potentially serious adverse events and development of bacterial resistance. Therefore, the indication of long-term antibiotic therapy must be determined on a case by case basis taking into account the potential risks and benefits. In general, this treatment may be indicated in patients with severe or very severe COPD with frequent or severe exacerbations despite optimal pharmacological and non pharmacological treatment. These patients should be carefully monitored based on clinical and microbiological assessments.The most appropriate drug and regime administration, as well as the optimal duration of therapy are issues that still require further investigation.

Long-acting bronchodilator use after hospitalization for COPD: an observational study of health insurance claims data.

BackgroundTreatment of stable chronic obstructive pulmonary disease (COPD) with long-acting bronchodilator (LABD) medications is recommended by the 2014 Global initiative for chronic Obstructive Lung Disease (GOLD) guidelines. The primary objective of this study was to examine LABD prescription fills after a COPD-related hospitalization.MethodsThis retrospective observational study used claims from Truven Health MarketScan® Commercial and Medicare Supplemental databases. Patients (age ≥40, commercial; age ≥65, Medicare supplemental) had a first hospitalization with a primary COPD diagnosis between April 1, 2009 and June 30, 2011 (index hospitalization) and were continuously enrolled for 1 year before and 9 months after hospitalization. Patients were categorized according to pre-index and/or post-index pharmacy claims.ResultsA total of 27,738 patients had an index hospitalization and met inclusion/exclusion criteria. Of those, 19,783 patients had COPD as a primary or secondary diagnosis during the year before index hospitalization and were included in the analysis. Approximately one quarter of the patients (26.32%) did not fill a prescription for an LABD or short-acting bronchodilator both 90 days before and 90 days after hospitalization. During the 90-day pre-index period, 40.57% of patients filled an LABD (with or without a short-acting bronchodilator) prescription. Over half of the patients (56.88%) filled an LABD prescription at some point during the 180-day post-index period, but, of those, a significantly greater proportion of patients filled an LABD prescription in the 1- to 90-day post-index period than in the 91- to 180-day post-index period (51.27% versus 43.66%; P<0.0001).ConclusionA significant proportion of COPD patients in this study did not fill an LABD prescription before hospitalization for COPD. Moreover, hospitalization did not appear to greatly impact LABD initiation. Lastly, patients who did not fill an LABD prescription within the first 90 days posthospitalization were not likely to fill an LABD prescription later. Taken together, the results of this study suggest that many patients with COPD are undertreated.

Posthospital follow-up visits and 30-day readmission rates in chronic obstructive pulmonary disease.

PurposeTo examine the effect of a follow-up visit with a primary care physician and/or pulmonologist within the first 30 days of hospital discharge on readmissions, emergency department (ED) visits, and mortality.Patients and methodsThis was a retrospective cohort study of 7,102 unique patients discharged from a Mayo Clinic hospital in Rochester, MN, and residing in Olmsted County, MN, with any mention of chronic obstructive pulmonary disease (COPD) from January 1, 2004 through November 30, 2011. The study included 839 patients who met study-entry criteria. Cox proportional hazards regression was performed to determine the risk of hospital readmission, ED visits, and death of patients, with or without a follow-up visit during the first 30 days postdischarge.ResultsOur results showed 839 unique patients experienced 1,422 discharges with a primary diagnosis of COPD. Of the 1,422 discharges, 973 (68.4%) had a follow-up visit within 30 days. In a multivariate Cox proportional hazard-ratio (HR) model analysis, occurrence of a follow-up visit did not have a significant effect on the risk of the combined outcome of 30-day readmission and ED visit (HR 0.947, confidence interval 0.763–1.177; P=0.63). However, a postdischarge follow-up visit had a significant effect on 30-day mortality (HR 0.279, confidence interval 0.149–0.523; P<0.001).ConclusionPostdischarge follow-up visits after hospitalization for COPD did not significantly reduce the risk of 30-day readmission or ED visit. However, patients who received postdischarge follow-up visits had significantly reduced 30-day mortality.

Fewer hospitalizations for chronic obstructive pulmonary disease in communities with smoke-free public policies.

We determined the impact of smoke-free municipal public policies on hospitalizations for chronic obstructive pulmonary disease (COPD). We conducted a secondary analysis of hospital discharges with a primary diagnosis of COPD in Kentucky between July 1, 2003, and June 30, 2011 using Poisson regression. We compared the hospitalization rates of regions with and without smoke-free laws, adjusting for personal and population covariates, seasonality, secular trends over time, and geographic region. Controlling for covariates such as sex, age, length of stay, race/ethnicity, education, income, and urban-rural status, among others, we found that those living in a community with a comprehensive smoke-free law or regulation were 22% less likely to experience hospitalizations for COPD than those living in a community with a moderate-weak law or no law. Those living in a community with an established law were 21% less likely to be hospitalized for COPD than those with newer laws or no laws. Strong smoke-free public policies may provide protection against COPD hospitalizations, particularly after 12 months, with the potential to save lives and decrease health care costs.

Benzodiazepine drug use and adverse respiratory outcomes among older adults with COPD.

Our purpose was to evaluate the association of new benzodiazepine use relative to non-use with adverse clinical respiratory outcomes among older adults with chronic obstructive pulmonary disease (COPD). This was a retrospective population-based cohort study of Ontario, Canada, residents between 2003 and 2010. A validated algorithm was applied to health administrative data to identify adults aged 66 years and older with COPD. Relative risks (RRs) of several clinically important respiratory outcomes were examined within 30 days of incident benzodiazepine use compared with non-use, applying propensity score matching. New benzodiazepine users were at significantly higher risk for outpatient respiratory exacerbations (RR 1.45, 95% CI 1.36-1.54) and emergency room visits for COPD or pneumonia (RR 1.92, 95% CI 1.69-2.18) compared to non-users. Risk of hospitalisation for COPD or pneumonia was also increased in benzodiazepine users, but was nonsignificant (RR 1.09, 95% CI 1.00-1.20). There were no significant differences in intensive care unit admissions between the two groups and all-cause mortality was slightly lower among new versus non-users. Benzodiazepines were associated with increased risk for several serious adverse respiratory outcomes among older adults with COPD. The findings suggest that decisions to use benzodiazepines in older patients with COPD need to consider potential adverse respiratory outcomes.

CHRNA3 and CYP3A5*3 genotype, lung function and chronic obstructive pulmonary disease in the general population

Genetic variations are most likely an additional risk factor besides tobacco smoking per se for the risk of chronic obstructive pulmonary disease (COPD). In this study, we compared genetic variants influencing the effect of smoking on COPD, that is, the effect of the well-known splicing defect polymorphism, CYP3A5*3 (rs776746), identified before genome-wide association studies, with the genome-wide association studies identified CHRNA3 (rs1051730) polymorphism on the risk of decreased lung function and COPD. In all, 10 605 participants from the general population were genotyped. Information on spirometry, hospital admissions and smoking behaviour was recorded. Endpoints were lung function and COPD. For CHRNA3, the percentage of forced expiratory volume in 1 s (FEV1%) predicted was 89.3, 90.6 and 92.4% in homozygous, heterozygous and noncarrier ever-smokers (P-trend<0.001). The corresponding values for forced vital capacity percentage (FVC%) predicted were 94.5, 95.2 and 96.7% (P-trend<0.001), and for FEV1/FVC ratio, the values were 0.753, 0.760 and 0.764 (P-trend=0.008). The odds ratio for COPD in homozygous versus noncarrier ever-smokers was 1.5 [95% confidence interval (CI) 1.3-1.9] for COPD hospitalization, 1.3 (95% CI 1.1-1.6) for COPD defined as FEV1/FVC less than lower limit of normal, 1.3 (95% CI 1.0-1.5) for the Global Initiative for Chronic Obstructive Lung Disease category 1-4 (GOLD 1-4), 1.2 (95% CI 1.0-1.5) for GOLD 2-4 and 1.5 (95% CI 1.1-2.2) for GOLD 3-4. This association could not be found in never-smokers. No association was found for CYP3A5*3. The CHRNA3 genotype is associated with decreased lung function and risk of COPD among ever-smokers, whereas this was not the case for CYP3A5*3.