Chronic Obstructive Pulmonary Disease Hospitalizations Research Articles

Long term exposure to fine particulate matter and development of chronic obstructive pulmonary disease in the elderly

Background Studies evaluating the role of long-term exposure to fine particulate matter (PM2.5) on chronic obstructive pulmonary disease (COPD) development showed inconsistent results and were limited to Western countries. We aimed to determine the association between long-term exposure to PM2.5 and COPD development in metropolitan cities in Korea, which have higher PM2.5 levels than those in Western country studies. Methods We constructed a retrospective cohort (elderly aged over 65 years who resided in 7 metropolitan cities in 2008) using Korea health insurance data. A total of 687,940 elderlies who had not visited hospitals due to COPD for 3 years (from 2008 to 2010) were followed-up from 2011 to 2016. The first hospital visit due to COPD during the follow-up period was regarded as COPD development. Daily district-level PM2.5 concentrations were estimated by chemical transport model and 60-month moving average PM2.5 were assigned to each subject in time-varying Cox proportional hazard model. Results The mean concentration of modelled PM2.5 in 7 metropolitan cities during the study period (from 2006 to 2016) was 28.0 μg/m3 and 259,700 subjects newly visited the hospital due to COPD. COPD hospital visit hazard ratio for a 10 μg/m3 increase in 60-month moving average PM2.5 concentration was 1.09 (95% confidence interval: 1.07, 1.11). Risks remained unchanged following different PM2.5 exposure levels (48-month moving average, and average PM2.5 concentrations for 2008 and 2008-2010) and in subgroup analysis by subject characteristics (sex, age, and income groups). Discussion By following-up 687,940 elderly subjects who resided in metropolitan cities in Korea for 6 years, long-term PM2.5 exposure showed association with COPD development.

Exposure to stressful life events among patients with chronic obstructive pulmonary disease: a prospective study.

Although depression and anxiety have been widely investigated among patients with chronic obstructive pulmonary disease (COPD), experiencing stressful life events and its effect on increasing risk of exacerbations was rarely assessed. This study aimed to clarify the association between facing with stressful events among COPD patients and their disease severity leading to hospitalization. A prospective study was conducted among 128 COPD patients from the population of Qazvin, a north-west, industrialized city of Iran from December 2017 to December 2018. Patients were followed up for one-year and their related measures were gathered. To compare variables among patients stratified by reporting stressful life conditions, Pearson's chi-square and Fisher's exact tests were used. Furthermore, to assess the effect of several covariates on the response variable, a logistic regression modelling was applied. Results were reported in form of odds ratios and their 95% confidence intervals. Study findings affirmed that patients who had experienced stressful situation had lower BMI, were retired, experienced more frequent exacerbations, and reported higher levels of anxiety/ depression. Moreover, those with stressful conditions were among current or former smokers (p < 0.05). Logistic regression analysis revealed that facing with stressful situations was significantly associated with the severity of COPD disease (OR 1.9; 95% CI 2.5 to 5.6), smoking habit (OR 2.8; 95% CI 1.6 to 4.2; OR 1.5; 95% CI 1.4 to 2.2), and hospitalization during one-year follow up (OR 1.2; 95% CI 1 to 3.3). To improve health outcomes of COPD patients, close attention should be given to their psychological disorder and appropriate strategies should be applied to reduce patients' exposure to stressful life events and subsequent anxieties.

Income inequalities in the risk of potentially avoidable hospitaliation and readmission for chronic obstructive pulmonary disease: a population data linkage analysis.

Hospitalizations for ambulatory care sensitive conditions, of which chronic obstructive pulmonary disease (COPD) is among the most common, represent an indirect measure of the healthcare system to manage chronic disease. Research has pointed to disparities in various COPD-related outcomes between persons of lower versus higher income; however, few studies have examined the influence of patients' social context on potentially avoidable COPD admissions. The research explores the use of linked population census and administrative health data to assess the influence of income inequalities on the risk of hospitalization and rehospitalization for COPD among Canadian adults. This analysis utilizes data from the 2006 Census linked longitudinally to the 2006/07-2008/09 Discharge Abstract Database. Multiple logistic regressions were conducted to assess the independent influence of income inequality on the risks of hospitalization and of six-month readmission due to COPD among the population aged 30-69, controlling for age, sex, education and other sociodemographic characteristics. Compared with adults in the most affluent income quintile, the adjusted odds of COPD hospitalization were significantly greater in the 4th highest income quintile (OR: 1.38; 95%CI: 1.30-1.47), and peaked for those in the least affluent quintile (OR: 2.92; 95%CI: 2.77-3.09). Among individuals who had been hospitalized at least once for COPD in the study period, and compared with the most affluent group, the adjusted odds of readmission were highest in the least affluent group (OR: 1.39; 95%CI: 1.22-1.58). Despite Canada's system of universal coverage for physician and hospital care, a clear income gradient in the risk of being hospitalized and, to some extent, rehospitalized for COPD, is found. Income inequalities may be contributing to excess hospitalizations, reinforcing the importance of integrating social and economic issues in primary care to meet the ambulatory needs of this population.

Income inequalities in the risk of potentially avoidable hospitalisation for chronic obstructive pulmonary disease

IntroductionHospitalizations for ambulatory care sensitive conditions, of which chronic obstructive pulmonary disease (COPD) is among the most common, represent an indirect measure of the healthcare system to manage chronic disease. Research has pointed to disparities in various COPD-related outcomes between persons of lower versus higher income; however, few studies have examined the influence of patients’ social context on potentially avoidable COPD admissions.ObjectiveThe research explores the use of linked population census and administrative health data to assess the influence of income inequalities on the risk of hospitalization and rehospitalization for COPD among Canadian adults.MethodsThis analysis utilizes data from the 2006 Census linked longitudinally to the 2006/07-2008/09 Discharge Database. Multiple logistic regressions were conducted to assess the independent influence of income inequality on the risks of hospitalization and of six-month readmission due to COPD among the population aged 30-69, controlling for age, sex, education and other sociodemographic characteristics.ResultsCompared with adults in the most affluent income quintile, the adjusted odds of COPD hospitalization were significantly greater in the 4th highest income quintile (OR: 1.38; 95%CI: 1.30–1.47), and peaked for those in the least affluent quintile (OR: 2.92; 95%CI: 2.77–3.09). Among individuals who had been hospitalized at least once for COPD in the study period, and compared with the most affluent group, the adjusted odds of readmission were highest in the least affluent group (OR: 1.39; 95%CI: 1.22–1.58).ConclusionsDespite Canada’s system of universal coverage for physician and hospital care, a clear income gradient in the risk of being hospitalized and, to some extent, rehospitalized for COPD, is found. Income inequalities may be contributing to excess hospitalizations, reinforcing the importance of integrating social and economic issues in primary care to meet the ambulatory needs of this population.

Reassessment of Home Oxygen Prescription after Hospitalization for Chronic Obstructive Pulmonary Disease. A Potential Target for Deimplementation.

Rationale: Hypoxemia associated with acute exacerbations of chronic obstructive pulmonary disease (COPD) often resolves with time. Current guidelines recommend that patients recently discharged with supplemental home oxygen after hospitalization should not have renewal of the prescription without assessment for hypoxemia. Understanding patterns of home oxygen reassessment is an opportunity to improve quality and value in home oxygen prescribing and may provide future targets for deimplementation.Objectives: We sought to measure the frequency of home oxygen reassessment within 90 days of hospitalization for COPD and determine the potential population eligible for deimplementation.Methods: We performed a cohort study of patients ≥40 years hospitalized for COPD at five Veterans Affairs facilities who were prescribed home oxygen at discharge. Our primary outcome was the frequency of reassessment within 90 days by oxygen saturation (SpO2) measurement. Secondary outcomes included the proportion of patients potentially eligible for discontinuation (SpO2 > 88%) and patients in whom oxygen was discontinued. Our primary exposures were treatment with long-acting bronchodilators, prior history of COPD exacerbation, smoking status, and pulmonary hypertension. We used a mixed-effects Poisson model to measure the association between patient-level variables and our outcome, clustered by site. We also performed a positive deviant analysis using chart review to uncover system processes associated with high-quality oxygen prescribing.Results: A total of 287 of 659 (43.6%; range 24.8-78.5% by site) patients had complete reassessment within 90 days. None of our patient-level exposures were associated with oxygen reassessment. Nearly half of those with complete reassessment were eligible for discontinuation on the basis of Medicare guidelines (43.2%; n = 124/287). When using the newest evidence available by the Long-Term Oxygen Treatment Trial, most of the cohort did not have resting hypoxemia (84.3%; 393/466) and would be eligible for discontinuation. The highest-performing Veterans Affairs facility had four care processes to support oxygen reassessment and discontinuation, versus zero to one at all other sites.Conclusions: Fewer than half of patients prescribed home oxygen after a COPD exacerbation are reassessed within 90 days. New system processes supporting timely reassessment and discontinuation of unnecessary home oxygen therapy could improve the quality and value of care.

Asthma and COPD Are Not Risk Factors for ICU Stay and Death in Case of SARS-CoV2 Infection

BackgroundAsthmatics and patients with chronic obstructive pulmonary disease (COPD) have more severe outcomes with viral infections than people without obstructive disease.ObjectiveTo evaluate if obstructive diseases are risk factors for intensive care unit (ICU) stay and death due to coronavirus disease 2019 (COVID19).MethodsWe collected data from the electronic medical record from 596 adult patients hospitalized in University Hospital of Liege between March 18 and April 17, 2020, for severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) infection. We classified patients into 3 groups according to the underlying respiratory disease, present before the COVID19 pandemic.ResultsAmong patients requiring hospitalization for COVID19, asthma and COPD accounted for 9.6% and 7.7%, respectively. The proportions of asthmatics, patients with COPD, and patients without obstructive airway disease hospitalized in the ICU were 17.5%, 19.6%, and 14%, respectively. One-third of patients with COPD died during hospitalization, whereas only 7.0% of asthmatics and 13.6% of patients without airway obstruction died due to SARS-CoV2. The multivariate analysis showed that asthma, COPD, inhaled corticosteroid treatment, and oral corticosteroid treatment were not independent risk factors for ICU admission or death. Male gender (odds ratio [OR]: 1.9; 95% confidence interval [CI]: 1.1-3.2) and obesity (OR: 8.5; 95% CI: 5.1-14.1) were predictors of ICU admission, whereas male gender (OR 1.9; 95% CI: 1.1-3.2), older age (OR: 1.9; 95% CI: 1.6-2.3), cardiopathy (OR: 1.8; 95% CI: 1.1-3.1), and immunosuppressive diseases (OR: 3.6; 95% CI: 1.5-8.4) were independent predictors of death.ConclusionAsthma and COPD are not risk factors for ICU admission and death related to SARS-CoV2 infection.

CHARACTERISTICS OF PATIENTS WITH FREQUENT EXACERBATOR PHENOTYPE OF COPD AND ROLE OF INHALED CORTICOSTEROID THERAPY

SESSION TITLE: Obstructive Lung Disease Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: Chronic Obstructive Pulmonary Disease (COPD) is a chronic pulmonary condition with a progressively increasing burden throughout the world and a high rate of hospitalization. The frequent exacerbator phenotype has been defined as the occurrence of two or more exacerbations per year and has been linked to negative clinical and psychosocial outcomes. We aimed to further characterize patients with frequent exacerbations and evaluate an association between inhaled corticosteroid therapy and the risk of hospital admission. METHODS: In this retrospective cohort study, we reviewed electronic medical records of 120 patients admitted to a hospital for COPD exacerbation at least once between January 1, 2016 and December 31, 2018. Characteristics of the frequent exacerbators were compared to patients with less frequent exacerbations or COPD. Cox proportional hazard model was used to evaluate an association between inhaled corticosteroid therapy and the risk of hospital admission. RESULTS: Patients in the frequent exacerbator cohort (n=69) were significantly younger, with lower percentage of women, compared to the patients with less frequent exacerbations (n=51). The median number of hospital admissions for COPD exacerbation were three and one, respectively. The frequent exacerbator cohort had significantly higher proportion of patients on supplemental oxygen at home and proportion of patients suffering from depression. No significant differences were observed in the disease severity, smoking status, or history of cardiovascular disease. After adjusting for age, sex, GOLD COPD stage and presence of restrictive lung disease, which had significant relationships with hospitalization for COPD in the univariate analysis, Cox proportional hazard regression analysis revealed increased risk for hospital admission associated with inhaled corticosteroid use at the time of admission (HR=1.57, p=0.017). CONCLUSIONS: We described patient characteristics associated with frequent exacerbator phenotype of COPD. Patients on inhaled corticosteroids experienced hospital admissions for COPD at a significantly higher rate. CLINICAL IMPLICATIONS: The knowledge of characteristics of patients with the frequent exacerbator phenotype of COPD may assist in the development of interventions aimed at decreasing the frequency of hospitalizations. The observed association between inhaled corticosteroid use and increased risk of hospital admission adds to the body of conflicting evidence as to the role of inhaled corticosteroids in the treatment of COPD. DISCLOSURES: No relevant relationships by John Chronakos, source=Web Response No relevant relationships by Manish Gupta, source=Web Response No relevant relationships by prajay rathore, source=Web Response No relevant relationships by Sushmita Shrestha, source=Web Response No relevant relationships by Oleg Sostin, source=Web Response No relevant relationships by Uladzislau Valynets, source=Web Response

Short-term effect of particular matter and sulfur dioxide exposure on asthma and/or chronic obstructive pulmonary disease hospital admissions in Center of Anatolia

We investigated the associations between the daily variations of coarse particulate matter (PM10) and/or sulfur dioxide (SO2) and hospital admissions for asthma and/or chronic obstructive pulmonary disease (COPD) diseases in Kirsehir, Center of Anatolia of Turkey. We analyzed the poison generalized linear model (GLM) to analyze the association between ambient air pollutants such as PM10 and SO2 and asthma and/or COPD admissions. We investigated single-lag days and multi-lag days for the risk increase in asthma, COPD, asthma, and/or COPD hospital admissions PM10, SO2, and PM10 with SO2 per 10 μg/m3. In single-lag day model a 10 μg/m3 increase in the current day (lag 0) concentrations of PM10 and SO2 corresponded to increase of 1.027 (95% CI:1.022-1.033) and 1.069 (95% CI:1.062, 1.077) for asthma. A 10 μg/m3 increase in the current day (lag 0) concentrations of PM10 and SO2 corresponded to increase of 1.029 (95% CI:1.022-1.035) and 1.065 (95% CI:1.056, 1.075) for COPD. A 10 μg/m3 increase in the current day (lag 0) concentrations of PM10 and SO2 corresponded to increase of 1.028 (95% CI:1.024-1.032) and 1.068 (95% CI:1.062, 1.074) for asthma and/or COPD. It was found that some lag structures were related with PM10 and SO2. Significant lags were detected in some lag structures from the previous first day until the previous eighth day (lag 1 to lag 7) in the asthma, COPD, and asthma and/or COPD hospital admissions in the model created with PM10 with SO2 both in the single-lag day model and in the multi-lag day model. Our study that used GLM in time series analysis showed that PM10 and/or SO2 short-term exposure in single-lag day and multi-lag day models was related with increased asthma, COPD, and asthma and/or COPD hospital admissions in the city between 2016 and 2019 until the previous-eighth day.

The global impact of Aspergillus infection on COPD

BackgroundAdvanced chronic obstructive pulmonary disease (COPD) often leads to hospitalisation and invasive aspergillosis (IA) is a serious complication. Aspergillus sensitisation may worsen symptoms in COPD.MethodsWe identified published papers between January 2000 and May 2019 with > 50 subjects and GOLD criteria for grade II, III or IV (FEV1/FVC < 70% and FEV1 < 80%) using standardised criteria in multiple countries, to re-estimate the prevalence of COPD. Hospitalised COPD patients develop IA in 1.3–3.9%, based on positive cultures of Aspergillus spp. and radiological findings. Given limited data on per-patient annual hospitalisation rates, we assumed a conservative 10.5% estimate. Annual IA mortality in COPD was estimated using the literature rates of 43–72%. A separate literature search assessed the impact of Aspergillus sensitisation on severity of COPD (by FEV1).ResultsWe re-estimated the global prevalence of COPD GOLD stages II-IV at 552,300,599 people (7.39% of the population) with 339,206,893 (8.58%) in Asia, 85,278,783 (8.52%) in the Americas, 64,298,051 (5.37%) in Africa, 59,484,329 (7.77%) in Europe and 4,032,543 (10.86%) in Oceania. An estimated 57,991,563 (10.5%) people with COPD are admitted to hospital annually and of these 753,073 (1.3%) – 2,272,322 (3.9%) develop IA and 540,451–977,082 deaths are predicted annually. Aspergillus sensitisation prevalence in COPD was 13.6% (7.0–18.3%) and not related to lower predicted FEV1% (P > 0.05).ConclusionsThe prevalence of COPD is much higher than previously estimated. Overall COPD mortality may be higher than estimated and IA probably contributes to many deaths. Improved rapid diagnosis of IA using culture and non-culture based techniques is required in COPD hospital admissions to reduce mortality.

Reduced mortality risk in malnourished hospitalized older adult patients with COPD treated with a specialized oral nutritional supplement: Sub-group analysis of the NOURISH study

Hospitalized, malnourished older adults with chronic obstructive pulmonary disease (COPD) have an elevated risk of readmission and mortality. Post-hoc, sub-group analysis from the NOURISH study cohort examined the effect of a high-protein oral nutritional supplement (ONS) containing HMB (HP-HMB) in malnourished, hospitalized older adults with COPD and to identify predictors of outcomes. The NOURISH study (n=652) was a multicenter, randomized, placebo-controlled, double-blind trial. The COPD subgroup (n=214) included hospitalized, malnourished (based on Subjective Global Assessment), older adults (≥65y), with admission diagnosis of COPD who received either standard-of-care plus HP-HMB (n=109) or standard-of-care and a placebo supplement (n=105) prescribed 2 servings/day from within 3 days of hospital admission (baseline) and up to 90 days after discharge. The primary study outcome was a composite endpoint of incidence of death or non-elective readmission up to 90-day post-discharge, while secondary endpoints included changes in hand-grip strength, body weight, and nutritional biomarkers over time. Categorical outcomes were analyzed using Cochran-Mantel-Haenszel tests, longitudinal data by repeated measures analysis of covariance; and changes from baseline by analysis of covariance. p-values ≤ 0.05 were considered statistically significant. Multivariate logistic regression was used to model predictors of the primary outcome and components. In patients with COPD, 30, 60, and 90-day hospital readmission rate did not differ, but in contrast, 30, 60, and 90-day mortality risk was approximately 71% lower with HP-HMB supplementation relative to placebo (1.83%, 2.75%, 2.75% vs. 6.67%, 9.52% and 10.48%, p=0.0395, 0.0193, 0.0113, resp.). In patients with COPD, compared to placebo, intake of HP-HMB resulted in a significant increase in handgrip strength (+1.56kg vs.-0.34kg, p=0.0413) from discharge to day 30; increased body weight from baseline to hospital discharge (0.66kg vs.-0.01kg, p<0.05) and, improvements in blood nutritional biomarker concentrations. The multivariate logistic regression predictors of the death, readmission or composite endpoints in these COPD patients showed that participants who were severely malnourished (p=0.0191) and had a Glasgow prognostic score (GPS) Score of 1 or 2 had statistically significant odds of readmission or death(p=0.0227). Among malnourished, hospitalized patients with COPD, supplementation with HP-HMB was associated with a markedly decreased mortality risk, and improved handgrip strength, body weight, and nutritional biomarkers within a 90-day period after hospital discharge. This post-hoc, subgroup analysis highlights the importance of early identification of nutritional risk and administration of high-protein ONS in older, malnourished patients with COPD after hospital admission and continuing after hospital discharge.

&lt;p&gt;Temperature Variability and Hospital Admissions for Chronic Obstructive Pulmonary Disease: Analysis of Attributable Disease Burden and Vulnerable Subpopulation&lt;/p&gt;

PurposeChronic obstructive pulmonary disease (COPD) is a major cause of chronic diseases causing considerable social and economic burden globally. Despite substantial evidence on temperature-COPD association, few studies have investigated the acute effect of temperature variability (TV), a potential trigger of exacerbation of COPD disease, and it remains unknown what fraction of the disease burden of COPD is attributable to TV.Patients and MethodsBased on 71,070 COPD hospitalizations during 2013–2015 in Guangzhou, China, we conducted a time-series analysis using quasi-Poisson regression to assess the association between TV and hospital admission for COPD after adjusting for daily mean temperature. Short-term TV was captured by the standard deviation of hourly or daily temperatures across various exposure days. We also provided the fraction (total number) of COPD attributable to TV. Stratified analyses by admission route, sex, age, occupation, marital status and season were performed to identify vulnerable subpopulations.ResultsWe found a linear relationship between TV and COPD hospitalization, with a 1°C increase in hourly TV and daily TV associated with 4.3% (95%CI: 2.2–6.4) and 4.0% (2.3–5.8) increases in COPD, respectively. The greater relative risks of TV identified males, people aged 0–64 years, blue collar, and divorced/widowed people as vulnerable population. There were 12.0% (8500 cases) of COPD hospitalization attributable to hourly TV during the study period. Daily TV produced similar estimates of relative effects (relative risk) but grater estimates of absolute effects (attributable fraction) than hourly TV.ConclusionWe concluded that TV was an independent risk factor of COPD morbidity, especially among the susceptible subgroups. These findings would be helpful to guide the development of targeted public intervention.

Readmissions Reduction Program: Mortality and Readmissions for Chronic Obstructive Pulmonary Disease.

Rationale: Implementation of the Hospital Readmissions Reduction Program (HRRP) following discharge of patients with chronic obstructive pulmonary disease (COPD) has led to a reduction in 30-day readmissions with unknown effects on postdischarge mortality.Objectives: To examine the association of HRRP with 30-day hospital readmission and 30-day postdischarge mortality rate in patients after discharge from COPD hospitalization.Methods: Retrospective cohort study of readmission and mortality rates in a national cohort (N = 4,587,542) of admissions of Medicare fee-for-service beneficiaries 65 years or older with COPD from 2006 to 2017.Measurements and Main Results: Data were analyzed for three nonoverlapping periods based on implementation of the HRRP specific to COPD: 1) preannouncement (December 2006 to March 2010), 2) announcement (April 2010 to August 2014), and 3) implementation (October 2014 to November 2017). The 30-day readmission rate decreased from 20.54% in the preannouncement period (December 2006 to July 2008) to 18.74% in the implementation period (May 2016 to November 2017). The 30-day risk-standardized postdischarge mortality rates were 6.91%, 6.59%, and 7.30% for the preannouncement, announcement, and implementation periods, respectively. Generalized estimating equations analyses estimated an additional 1,196 deaths (October 2014 to April 2016) and 3,858 deaths (May 2016 to November 2017) during the HRRP implementation period.Conclusions: We found a reduction in 30-day all-cause readmission rate during the implementation period compared with the preannouncement phase. HRRP implementation was also associated with a significant increase in 30-day mortality after discharge from COPD hospitalization. Additional research is necessary to confirm our findings and understand the factors contributing to increased mortality in patients with COPD in the HRRP implementation period.

Effect of a pulmonary rehabilitation programme of 8 weeks compared to 12 weeks duration on exercise capacity in people with chronic obstructive pulmonary disease (PuRe Duration): protocol for a randomised controlled trial

IntroductionPulmonary rehabilitation (PR) is a key component in the management of chronic obstructive pulmonary disease (COPD). There is no strong evidence on the optimal duration of PR programmes. The aim...

Potential barriers to physician follow-up within 7 days of discharge from a chronic obstructive pulmonary disease hospital admission

RATIONALE: Given that physician follow-up after hospital may reduce readmissions for patients with chronic obstructive pulmonary disease (COPD), understanding factors associated with follow-up could help to improve discharge transitions. OBJECTIVES: To determine rate and factors associated with physician follow-up within 7 days of discharge from a COPD-related hospitalization. METHODS: Population-based retrospective cohort study of patients with COPD discharged from an Ontario hospital between April 1, 2010 and March 31, 2016 using health administrative data. All patients > =35 years old were included. The primary outcome was follow-up with family doctor, respirologist or internal medicine specialist within 7 days of discharge. Multivariable logistic regression analysis was used to determine demographic, socioeconomic, provider and health care access variables associated with follow-up. MEASUREMENTS AND MAIN RESULTS: Overall, 24,438 (29.8%) out of 81,960 patients had physician follow-up within 7 days of discharge. Women (OR 0.89, 95% CI 0.86-0.91), rural dwellers (OR 0.86, 95% CI 0.82-0.90), patients without a family doctor (OR 0.38, 95% CI 0.34-0.44) and those from low-income regions, or those who had hospital length-of-stay >7 days (OR 0.81, 95% CI 0.78-0.85) were less likely to receive follow-up within 7 days. Patients were more likely to receive follow-up if they required intensive care (OR 1.07, 95% CI 1.02-1.12) or had seen a physician frequently in the past. CONCLUSIONS: Fewer than 1 in 3 patients received early follow-up. Barriers to follow-up may exist for women, rural-dwellers, patients without a family doctor, those residing in low-income regions, or who experienced prolonged hospital stays.

Causes of hospitalization and characteristics of Algerian chronic obstructive pulmonary disease patients in Tizi-Ouzou: a retrospective study.

Chronic obstructive pulmonary disease (COPD) is a progressive chronic inflammatory disease and the third cause of death worldwide in 2016. COPD epidemiology is well documented in high-income countries where the disease is well managed. However, the disease is neglected in low-income countries and there is lack of data. Our study aims to identify COPD patients' characteristics and hospital admission causes, and to determine disease etiologies and associated factors. A retrospective study was conducted in COPD Algerian patients using medical record data collected from January 2007 to May 2017 at the pulmonology department of the Belloua Hospital of Tizi-Ouzou city. Out of 133 hospital admissions for COPD during the study period, only 120 records were found and analyzed. Most of the admitted patients were men (96%) and the mean age was 74.29±9.56 years. Among them, 78.7% were in the GOLD stage III or IV and 9 deaths (7.5%) were recorded during the study period. Interestingly, disease severity is associated with increasing age of the patients and mortality (p=0.01 and p=0.02, respectively). Risk factors include cigarette smoking (93%), history of medical conditions (36.66%) with the most prevalent conditions being emphysema (38.63%) and asthma (27.27%), the cold season (47%), and occupational exposures (58%). Most of the admissions (64.16%) were due to acute dyspnea and 21.66 % to respiratory infections, however, 34.16 % of patients were readmitted at least one time. Comorbidities were observed in 57.5% of the patients, including cardiovascular diseases (63.76%) and diabetes (18.84%). These results show that COPD severity is associated with age and mortality. Better understanding of the COPD etiologies and the causes of hospital admission will lead to more effective management of the disease.

Implementation of the chronic obstructive pulmonary disease Assessment Test in clinical practice.

The chronic obstructive pulmonary disease (COPD) Assessment Test (CAT) is a questionnaire used for COPD symptom assessment that is valid, reliable, and evidence based; yet, few specialty or primary care practices have formally implemented it in practice. The University of Colorado's pulmonary division has consistently been rated the best in the country by US News and World Reports; however, the dedicated multidisciplinary COPD clinic at the University had yet to formally implement any COPD Assessment tools for COPD symptom management. This quality improvement project focused on the successful implementation of the CAT for management of COPD and whether its use impacts symptom management. Plan-Do-Study-Act cycles were used to implement the CAT questionnaire in the outpatient COPD clinic from April 16 to September 30, 2019. Weekly retrospective chart evaluation was completed to evaluate CAT completion, documentation, and associated medical intervention rates. Weekly patient phone surveys were completed on qualifying COPD patients to garner patient opinion on the utility of the CAT in symptom management. The CAT was administered to all COPD patients in University of Colorado Hospital's COPD clinic. Cat-themed signs, decorations, and treats were provided to staff on COPD clinic days to increase staff buy-in. The CAT was completed on 217 of 245 (89%) patients with COPD. Of patients surveyed, 81% (n = 53) noted that their symptoms were better managed after CAT implementation. Implementation and utilization of COPD assessment tools, like the CAT, are practical and sustainable in a specialty practice setting. Moreover, the CAT helps with COPD symptom management.

The Summit Score Stratifies Mortality and Morbidity in Chronic Obstructive Pulmonary Disease.

IntroductionTobacco use and other cardiovascular risk factors often accompany chronic obstructive pulmonary disease (COPD). This study derived and validated the Summit Score to predict mortality in people with COPD and cardiovascular risks.MethodsSUMMIT trial subjects (N=16,485) ages 40–80 years with COPD were randomly assigned 50%/50% to derivation (N=8181) and internal validation (N=8304). Three external COPD validations from Intermountain Healthcare included outpatients with cardiovascular risks (N=9251), outpatients without cardiovascular risks (N=8551), and inpatients (N=26,170). Cox regression evaluated 40 predictors of all-cause mortality. SUMMIT treatments including combined fluticasone furoate (FF) 100μg/vilanterol 25μg (VI) were not included in the score.ResultsMortality predictors were FEV1, heart rate, systolic blood pressure, body mass index, age, smoking pack-years, prior COPD hospitalizations, myocardial infarction, heart failure, diabetes, anti-thrombotics, anti-arrhythmics, and xanthines. Combined in the Summit Score (derivation: c=0.668), quartile 4 vs 1 had HR=4.43 in SUMMIT validation (p<0.001, 95% CI=3.27, 6.01, c=0.662) and HR=8.15 in Intermountain cardiovascular risk COPD outpatients (p<0.001, 95% CI=5.86, 11.34, c=0.736), and strongly predicted mortality in the other Intermountain COPD populations. Among all SUMMIT subjects with scores 14–19, FF 100μg/VI 25μg vs placebo had HR=0.76 (p=0.0158, 95% CI=0.61, 0.95), but FF 100μg/VI 25μg was not different from placebo for scores <14 or >19.ConclusionIn this post hoc analysis of SUMMIT trial data, the Summit Score was derived and validated in multiple Intermountain COPD populations. The score was used to identify a subpopulation in which mortality risk was lower for FF 100μg/VI 25μg treatment.Trial RegistrationThe SUMMIT trial is registered at ClinicalTrials.gov as number NCT01313676.

Clinical Impact and Healthcare Resource Utilization Associated with Early versus Late COPD Diagnosis in Patients from UK CPRD Database.

PurposePrevious studies have shown that opportunities to diagnose chronic obstructive pulmonary disease (COPD) early are often missed in primary care. This retrospective study aimed to utilize secondary data from the United Kingdom (UK) healthcare system to understand the impact of early versus late diagnosis of COPD.Patients and MethodsNewly diagnosed COPD patients were identified in the UK Clinical Practice Research Database from 2011 to 2014. Patients whose 5-year medical data before diagnosis revealed ≥3 counts of eight indicators of early COPD were deemed as late-diagnosed, whereas others were deemed as early-diagnosed. We assessed patients’ characteristics; time-to-first, risk, and rates of exacerbation; and healthcare resource utilization (COPD-related clinic visits, Accident and Emergency visits, and hospitalizations) in late- versus early-diagnosed patients.ResultsOf 10,158 patients included in the study, 6783 (67%) were identified as late-diagnosed and 3375 (33%) as early-diagnosed. The median time-to-first exacerbation was shorter in late-diagnosed (14.5 months) versus early-diagnosed (29.0 months) patients, with a significant risk of exacerbation (hazard ratio 1.46 [95% confidence interval: 1.38–1.55]). Additionally, the exacerbation rate (per 100 person-years) over 3 years was higher in late (108.9) versus early (57.2) diagnosed patients. Late-diagnosed patients had a significantly higher rate of COPD hospitalizations (per 1000 patient years) compared with early-diagnosed patients during 2 and 3 years of follow-ups (P = 0.0165 and P < 0.0001, respectively).ConclusionResults showed that a significant percentage of COPD patients in UK primary care are diagnosed late. A late COPD diagnosis is associated with a shorter time-to-first exacerbation and a higher rate and risk of exacerbations compared with early diagnosis. Additionally, late diagnosis of COPD is associated with a higher rate of COPD-related hospitalizations compared with early diagnosis.

Long-term exposure to fine particulate matter and development of chronic obstructive pulmonary disease in the elderly

BackgroundStudies evaluating the role of long-term exposure to fine particulate matter (PM2.5) on chronic obstructive pulmonary disease (COPD) development showed inconsistent results and were limited to Western countries. We aimed to determine the association between long-term exposure to PM2.5 and COPD development in metropolitan cities in Korea, which have higher PM2.5 levels than those in Western country studies. MethodsWe constructed a retrospective cohort (elderly aged over 65 years who resided in 7 metropolitan cities in 2008) using Korea health insurance data. A total of 687,940 elderlies who had not visited hospitals due to COPD for 3 years (from 2008 to 2010) were followed-up from 2011 to 2016. The first hospital visit due to COPD during the follow-up period was regarded as COPD development. Daily district-level PM2.5 concentrations were estimated by chemical transport model and 60-month moving average PM2.5 were assigned to each subject in time-varying Cox proportional hazard model. ResultsThe mean concentration of modelled PM2.5 in 7 metropolitan cities during the study period (from 2006 to 2016) was 28.0 μg/m3 and 259,700 subjects newly visited the hospital due to COPD. COPD hospital visit hazard ratio for a 10 μg/m3 increase in 60-month moving average PM2.5 concentration was 1.09 (95% confidence interval: 1.07, 1.11). Risks remained unchanged following different PM2.5 exposure levels (48-month moving average, and average PM2.5 concentrations for 2008 and 2008–2010) and in subgroup analysis by subject characteristics (sex, age, and income groups). DiscussionBy following-up 687,940 elderly subjects who resided in metropolitan cities in Korea for 6 years, long-term PM2.5 exposure showed association with COPD development.

Respiratory outcomes of metformin use in patients with type 2 diabetes and chronic obstructive pulmonary disease

Few studies investigated the respiratory outcomes of metformin use in patients with coexistent type 2 diabetes mellitus (T2DM) and chronic obstructive pulmonary disease (COPD). We want to compare the long-term respiratory endpoints of metformin use and nonuse in patients with T2DM and COPD. This retrospective cohort study enrolled patients with T2DM and COPD from Taiwan’s National Health Insurance Program between January 1, 2000, and December 31, 2012. Main outcomes were hospitalized bacterial pneumonia, hospitalization for COPD, noninvasive positive pressure ventilation (NIPPV), invasive mechanical ventilation (IMV), and lung cancer. In total, 20,644 propensity score-matched metformin users and nonusers were assessed. The adjusted hazard ratios (95% confidence intervals) of metformin use relative to nonuse for bacterial pneumonia, hospitalization for COPD, NIPPV, IMV, and lung cancer were 1.17 (1.11–1.23), 1.34 (1.26–1.43), 0.99 (0.89–1.10), 1.10 (1.03–1.17), and 1.12 (0.96–1.30). Metformin use also exhibited significant dose–response relationship with respect to the risks of bacterial pneumonia, hospitalization for COPD and IMV. Consistent results were found in the sensitivity test. This nationwide cohort study demonstrated that in patients with T2DM and COPD, metformin use was associated with higher risks of pneumonia, hospitalization for COPD, and IMV. If patients with COPD use metformin, vigilance with regard to their pulmonary condition may be required.