COPD-related Hospitalizations Research Articles

Muscle loss phenotype in COPD is associated with adverse outcomes in the UK Biobank

BackgroundChronic obstructive pulmonary disease (COPD) is a chronic inflammatory disorder with systemic consequences that can cause a muscle loss phenotype (MLP), which is characterized by the loss of muscle mass, muscle strength, or loss of both muscle and fat mass. There are limited data comparing the individual traits of MLP with clinical outcomes in a large unbiased cohort of COPD patients. Our aim was to determine the proportion of patients who met criteria for MLP in an unbiased sample of COPD patients at the population-level. We also determined if specific MLP features were associated with all-cause and COPD-related mortality.MethodsA retrospective population-based cohort analysis of the UK Biobank was performed. COPD was defined by a FEV1/FVC ratio < 0.7, physician established diagnosis of COPD, or those with a COPD-related hospitalization before baseline assessment. MLP included one or more of the following: 1) Low fat-free mass index (FFMI) on bioelectric impedance analysis (BIA) or 2) Appendicular skeletal muscle index (ASMI) on BIA, 3) Low muscle strength defined by handgrip strength (HGS), or 4) Low muscle and fat mass based on body mass index (BMI). Cox regression was used to determine the association between MLP and all-cause or COPD-related mortality. All models were adjusted for sex, age at assessment, ethnicity, BMI, alcohol use, smoking status, prior cancer diagnosis and FEV1/FVC ratio.ResultsThere were 55,782 subjects (56% male) with COPD followed for a median of 70.1 months with a mean(± SD) age at assessment of 59 ± 7.5 years, and FEV1% of 79.2 ± 18.5. Most subjects had mild (50.4%) or moderate (42.8%) COPD. Many patients had evidence of a MLP, which was present in 53.4% of COPD patients (34% by ASMI, 26% by HGS). Of the 5,608 deaths in patients diagnosed with COPD, 907 were COPD-related. After multivariate adjustment, COPD subjects with MLP had a 30% higher hazard-ratio for all-cause death and 70% higher hazard-ratio for COPD-related death.ConclusionsEvidence of MLP is common in a large population-based cohort of COPD and is associated with higher risk for all-cause and COPD-related mortality.

The effect of an educational program on wellbeing and symptom control of hospitalized chronic obstructive pulmonary disease patients in Jordan

ABSTRACT This study was conducted to determine what impact a structured nurse-led educational program has on patient self management and symptom control of hospitalized Chronic Obstructive Pulmonary Disease (COPD) patients in Jordan. An experimental design was used to guide data collection from 100 COPD patients who were randomly assigned to the intervention (n = 50) and control groups (n = 50). Participants in the intervention group underwent a two-week health education program that discussed smoking, medications and how to use them, exercise, and diet. A COPD educational pamphlet was also provided. Participants in the control group received only routine health education. A COPD Assessment Test (CAT) was used to measure the impact of the COPD educational program on wellbeing. The test consists of eight short questions covering cough, sputum production, chest tightness, breathlessness, activity limitations at home, confidence leaving home, sleep, and energy. The independent samples t-test findings revealed a significant difference between the two groups in relation to the post-test results (p = 0.039), with a 95 percent confidence interval −25.24 to −6.46, providing empirical support for the educational program’s success. Moreover, and as compared to the control group, participants in the intervention group showed significantly fewer COPD-related hospital admissions (p = .033). These programs should be integral components of a nurse-led COPD clinic to improve patients’ experience with the disease and reduce the risk of readmission, resulting in reduced cost and improved quality of life.

Nontuberculous mycobacterial pulmonary disease added burden to COPD and bronchiectasis in Japan

Background and objectiveNontuberculous mycobacterial pulmonary disease (NTM-PD) prevalence in Japan is among the highest worldwide. Chronic obstructive pulmonary disease (COPD) and bronchiectasis are common comorbidities among patients with NTM-PD, and it is challenging to treat NTM-PD in patients with these conditions. There are limited data on the incremental burden that NTM-PD adds to underlying COPD or bronchiectasis in Japan. Therefore, the objective of this study was to assess the incremental burden associated with NTM-PD in patients with pre-existing COPD and/or bronchiectasis.MethodsThis nested case-control study was based on JMDC, Inc. (JMDC) claims data (2015–2020). Patients with COPD and/or bronchiectasis with NTM-PD (cases) were age and sex matched 1:3 to patients with COPD and/or bronchiectasis without NTM-PD (controls), resulting in 3 mutually exclusive patient groups (COPD, bronchiectasis, or both, with/without NTM-PD). Incremental burden of NTM-PD was assessed within each group by comparing hospitalisations during the 1-year period after NTM-PD diagnosis (index) between cases and controls with both univariate analysis and multivariate analysis adjusting for pre-index comorbidities.ResultsUnivariate analyses in the 3 patient groups consistently demonstrated incremental hospitalisation burden in casesversuscontrols (eg, COPD group: 20% of 492 casesversus13% of 1476 controls had all-cause hospitalisations; 11%versus5% had respiratory-related hospitalisations; and 6%versus2% had COPD-related hospitalisations). Subsequent multivariate analysis further confirmed the findings.ConclusionsThe substantial incremental burden of hospitalisation associated with NTM-PD in patients with COPD and/or bronchiectasis highlights the urgent need for appropriate management of NTM-PD in Japan.

Comprehensive care plans for patients with Chronic Obstructive Pulmonary Disease (COPD): Effect on health services utilization

RATIONALE There is limited real-world evidence on evaluation of chronic disease management initiatives provided by general physicians to patients with chronic obstructive pulmonary disease (COPD). OBJECTIVES We aimed to evaluate changes in COPD-related healthcare resource utilization between COPD patients who had general physician’s provided comprehensive annual care plan (CACP) and those who did not have CACP. METHODS We conducted a retrospective cohort study using health administrative data (Alberta) from 2009 to 2016. COPD patients who received a CACP were identified and matched with two control patients based on age, sex, provider, date of service and qualifying comorbidities. Controlled interrupted-time series analysis was used to evaluate changes in COPD-specific hospitalizations, emergency department (ED) visits, physician visits and claims for pulmonary function test (PFT). Immediate and temporal changes were calculated for the difference in outcomes 1 year before and 1 year after receiving the CACP for the intervention group and matched controls. RESULTS Eligible patients (N = 88,002), of whom 35,847 had received CACPs were matched to a total of 52,155 controls. In 1 year after the CACPs implementation the number of COPD-related hospitalization visits significantly increased by 105.33 (95% CI 58.17-152.49), ED visits increased by 172.65 (95% CI 168.09–177.20), general practitioners (GP) visits increased by 359.53 (95% CI 247.64–471.41), specialist visits increased by 77.21 (95% CI 31.58–122.85) and PFT claims increased by 50.82 (95% CI 35.33–66.30) when compared to the controls who did not receive CACP per 10,000 patients per month. However, only increase in ED and specialist visits was confirmed by the sensitivity analysis. CONCLUSIONS Annual care plans provided by physicians were found to be associated with a statistically significant increase in COPD-related events (including ED visits) in the following year; however, clinical significance was minimal.

Cluster randomised controlled trial of specialist-led integrated COPD care (INTEGR COPD)

ObjectiveStudies in hospital settings demonstrate that there is greater guideline adherence when care is delivered by a respiratory specialist, however, this has not been explored in primary care. The aim...

Clinical and economic burden of anxiety/depression among older adult COPD patients: evidence from the COPD-AD China Registry study.

Anxiety and depression are common in patients with chronic obstructive pulmonary disease (COPD), especially older adult patients. This can complicate the disease progression and lead to increased clinical and economic burden. We sought to investigate the clinical and economic burdens associated with the presence of anxious and/or depressive symptoms among older adult COPD patients. We screened 579 patients aged over 60 years and diagnosed with COPD via a lung function test following the 2017 Global Initiative Chronic Obstructive Lung Disease (GOLD) guidelines. Anxiety and depression were measured using the Hospital Anxiety and Depression Scale (HADS) through face-to-face interviews at admission. Follow-up was conducted by telephone calls at 6, 12, 18, 24, and 36 months after discharge to assess clinical and economic burden. COPD-anxiety and/or depression patients were matched to patients without anxiety and depression (COPD-only) using propensity scores. Multivariate regression models were used to compare clinical and economic burden between COPD-anxiety and/or depression and COPD-only groups. Compared with COPD-only patients, COPD patients complicated with anxiety and/or depression had increased clinical burden, including higher COPD-related outpatient visits, COPD-related hospitalizations, and length of COPD-related hospitalizations (p < 0.001). Moreover, they also had an increased economic burden, including higher annual total healthcare costs, medical costs, and pharmacy costs (p < 0.001). Older adult COPD patients with anxiety or depression had significantly higher clinical and economic burdens than patients without these comorbidities. These findings deserve further exploration and may be useful for the formulation of relevant healthcare policies.

Increased Risk of Incident Chronic Obstructive Pulmonary Disease and Related Hospitalizations in Tuberculosis Survivors: A Population-Based Matched Cohort Study.

Tuberculosis (TB) survivors have an increased risk of developing chronic obstructive pulmonary disease (COPD). This study assessed the risk of COPD development and COPD-related hospitalization in TB survivors compared to controls. We conducted a population-based cohort study of TB survivors and 1:1 age- and sex-matched controls using data from the Korean National Health Insurance Service database collected from 2010 to 2017. We compared the risk of COPD development and COPD-related hospitalization between TB survivors and controls. Of the subjects, 9.6% developed COPD, and 2.8% experienced COPD-related hospitalization. TB survivors had significantly higher COPD incidence rates (36.7/1,000 vs. 18.8/1,000 person-years, P < 0.001) and COPD-related hospitalization (10.7/1,000 vs. 4.3/1,000 person-years, P < 0.001) than controls. Multivariable Cox regression analyses revealed higher risks of COPD development (adjusted hazard ratio [aHR], 1.63; 95% confidence interval [CI], 1.54-1.73) and COPD-related hospitalization (aHR, 2.03; 95% CI, 1.81-2.27) in TB survivors. Among those who developed COPD, the hospitalization rate was higher in individuals with post-TB COPD compared to those with non-TB COPD (10.7/1,000 vs. 4.9/1,000 person-years, P < 0.001), showing an increased risk of COPD-related hospitalization (aHR, 1.84; 95% CI, 1.17-2.92). TB survivors had higher risks of incident COPD and COPD-related hospitalization compared to controls. These results suggest that previous TB is an important COPD etiology associated with COPD-related hospitalization.

Decreasing COPD-related incidences and hospital admissions in a German health insurance population

Chronic obstructive pulmonary disease (COPD) is associated with smoking and work-related health hazards. Most studies have reported prevalences, and the number of studies examining incidences and social inequalities is small. We analyzed the development of social inequalities of COPD-incidences in terms of income and exacerbations in terms of hospital admissions. Findings were based on claims data from a German statutory health insurance covering 2008 to 2019. Outpatient diagnoses were used for defining COPD-cases, hospital admissions were used for detecting exacerbations. Analyses were performed using Cox-regression. Individual incomes were depicted at three levels defined according to national averages for each year. Data of 3,040,137 insured men and women were available. From 2008 to 2019 COPD-incidences in men decreased by 42% and 47% in women. After stratification by income the reduction at the lowest income level was 41% and 50% in women. Respectively, at the highest income level reductions were 28% and 41%. Disease exacerbations decreased over time, and also social inequalities between income groups emerged. COPD-rates decreased over time at all income levels, but at a faster pace in the lowest income group, thus leading to a positive development of diminishing social gradients in men as well as in women.

Intensive out-of-hospital coaching for frequently hospitalized COPD patients: a before-after feasibility study.

This study assesses whether out-of-hospital coaching of re-hospitalized, severe COPD patients by specialized respiratory nurses is feasible in terms of cost-effectiveness, implementation, and recipient acceptability. The coaching was aimed at improving patients' health management abilities, motivation for healthy behavior, strengthening the professional and informal care network, stimulating physiotherapy treatment and exercise training, improving knowledge on symptom recognition and medication use, and providing safety and support. Cost-effectiveness of 6 months of out-of-hospital coaching was assessed based on a before-after intervention design, with real-life data and one-year follow-up. A total of 170 patients were included. Primary (questionnaires, meeting reports) and secondary data (insurance reimbursement data) were collected in one province in the Netherlands. The implementing and recipient acceptability was assessed based on the number of successfully delivered coaching sessions, questionnaire response rate, Patient Reported Experience Measure, and interviews with coaches. Post-intervention, the COPD-related hospitalization rate was reduced by 24%, and patients improved in terms of health status, anxiety, and nutritional status. Patients with a high mental burden and a poor score for health impairment and wellbeing at the start of the intervention showed the greatest reduction in hospitalizations. The coaching service was successfully implemented and considered acceptable by recipients, based on patient and coach satisfaction and clinical use of patient-reported measures. The study demonstrates the value of coaching patients out-of-hospital, with a strong link to primary care, but with support of hospital expertise, thereby adding to previous studies on disease- or self-management support in either primary or secondary care settings. Patients benefit from personal attention, practical advice, exercise training, and motivational meetings, thereby improving health status and reducing the likelihood of re-hospitalization and its associated costs.

Association between fresh fruit consumption and the risk of chronic obstructive pulmonary disease-related hospitalization and death in Chinese adults: A prospective cohort study.

Existing evidence suggests that fruit consumption is a significant influencing factor for chronic obstructive pulmonary disease (COPD), but this is unclear in the Chinese population. We examined the association of fresh fruit consumption with the risk of COPD-related hospitalization and death in a nationwide, population-based prospective cohort from China. Between 2004 and 2008, the China Kadoorie Biobank recruited >0.5 million adults aged 30 to 79 years from ten diverse regions across China. After excluding individuals diagnosed with major chronic diseases and prevalent COPD, the prospective analysis included 421,428 participants. Cox regression was used to calculate the hazard ratios (HRs) for the association between fresh fruit consumption and risk of COPD-related hospitalization and death, with adjustment for established and potential confounders. During a mean follow-up of 10.9 years, 11,292 COPD hospitalization events and deaths were documented, with an overall incidence rate of 2.47/1000 person-years. Participants who consumed fresh fruit daily had a 22% lower risk of COPD-related hospitalization and death compared with non-consumers (HR = 0.78, 95% confidence interval [CI]: 0.71-0.87). The inverse association between fresh fruit consumption and COPD-related hospitalization and death was stronger among non-current smokers and participants with normal body mass index (BMI) (18.5 kg/m 2 ≤ BMI < 24.0 kg/m 2 ); the corresponding HRs for daily fresh fruit consumption were 0.78 (95% CI: 0.68-0.89) and 0.69 (95% CI: 0.59-0.79) compared with their counterparts, respectively. High-frequency fruit consumption was associated with a lower risk of COPD in Chinese adults. Increasing fruit consumption, together with cigarette cessation and weight control, should be considered in the prevention and management of COPD.

Systematic Review and Meta-Analysis of Psychological Distress and Acute Exacerbation of Chronic Obstructive Pulmonary Disease and Consequences.

People with chronic obstructive pulmonary disease (COPD) occasionally develop acute exacerbation of COPD-a potentially fatal condition. Psychological distress was associated with acute exacerbation of COPD. However, the evidence on the effect of psychological distress on acute exacerbation of COPD remains unclear. To explore the influence of psychological distress on acute exacerbation of COPD and its consequences. The current review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using three databases (PubMed, CINAHL, and PsyINFO) that were searched to identify relevant articles. Pooled risk ratios and 95% confidential interval were calculated from the included studies' data with random-effect methods to estimate the effect of psychological distress on acute exacerbation of COPD and its consequences. Nineteen articles were included in the review. Most revealed that psychological distress was significantly associated with increased risk of acute exacerbation of COPD and its consequences. The meta-analyses showed that psychological distress increased risk of acute exacerbation of COPD, COPD-related hospitalization, and death. Psychological distress had negative effects on acute exacerbation of COPD and its consequences. The results of the meta-analyses show that persons with COPD and psychological distress had a greater risk of acute exacerbation of COPD, hospitalization, and death.

Benefit of prompt initiation of single-inhaler fluticasone furoate, umeclidinium, and vilanterol (FF/UMEC/VI) in patients with COPD in England following an exacerbation: a retrospective cohort study

BackgroundTriple therapy is recommended for patients with chronic obstructive pulmonary disease (COPD) who remain symptomatic despite dual therapy. The optimal timing of triple therapy following an exacerbation of COPD is unknown. The outcomes of prompt (≤ 30 days) vs. delayed (31–180 days) initiation of single-inhaler triple therapy with fluticasone furoate, umeclidinium, and vilanterol (FF/UMEC/VI) following an exacerbation of COPD were examined.MethodsThis was a retrospective cohort study of linked English primary (Clinical Practice Research Datalink) and secondary (Hospital Episode Statistics) care data. Patients aged ≥ 35 years with COPD were indexed on the first and/or earliest date of exacerbation between November 15, 2017 and March 31, 2019 with subsequent FF/UMEC/VI initiation within 180 days. Patients were required to be continuously registered with a general practitioner for ≥ 12 months prior to and following index. Subsequent exacerbations, direct medical costs, and hospital readmissions were compared between prompt and delayed initiators. Inverse probability of treatment weighting was used to adjust for measured confounders between cohorts.ResultsOverall, 1599 patients were included (prompt: 393, delayed: 1206). After weighting, prompt initiators had numerically lower moderate/severe exacerbations compared with delayed initiators (rate ratio: 0.87, 95% confidence interval [CI]: 0.76–1.01, p = 0.0587). Both all-cause and COPD-related 30-day hospital readmissions were significantly lower among patients with prompt initiation compared with delayed initiators (all-cause: 23.6% vs. 34.6%, odds ratio [95% CI]: 0.58 [0.36–0.95], p = 0.0293; COPD-related: 20.3% vs. 30.6%, odds ratio [95% CI]: 0.58 [0.35–0.96], p = 0.0347). Prompt initiators also had numerically lower all-cause total costs and significantly lower COPD-related costs per-person-per year compared with delayed initiators (COPD-related: £742 vs. £801, p = 0.0016).ConclusionPrompt initiation of FF/UMEC/VI following a moderate/severe exacerbation was associated with fewer subsequent exacerbations, fewer hospital readmissions, and lower COPD-related medical costs compared with delayed initiation.

Impact of COVID-19 and lockdown on COPD admissions to Christchurch Hospital, New Zealand 2020-2021: a combined quantitative and qualitative study.

During the year following New Zealand's first COVID-19 lockdown, a 33% reduction in chronic obstructive pulmonary disease (COPD)-related admissions occurred and persisted beyond this period at Christchurch Hospital. To identify contributing factors which may have resulted in a persistent decrease in COPD hospitalisation rates at Christchurch Hospital following the 2020 COVID-19 lockdown. Using an explanatory sequential mixed-methods research design, we (i) retrospectively analysed hospital admissions and primary healthcare access by people with COPD (n = 1358) in Canterbury before, during and after COVID lockdown (24 March 2019 to 2021) and (ii) undertook individual interviews from a sample of patients (n = 14). Patients who were not re-admitted following the COVID-19 lockdown had fewer general practice encounters, acute primary care access, antibiotic and prednisone prescriptions. Proportionally fewer Māori and more Pacific patients were admitted with COPD following lockdown. Positive contributing factors at a primary care level included improvements in primary care interactions and medication management. At a patient and community level, there were improvements in lifestyle, self-management practices, social support and contact precautions. However, a subgroup of patients described negative effects such as social isolation. A combination of patient, primary care and community-level factors led to an overall persistent decrease in COPD admissions following the COVID-19 lockdown. Future targeted and individualised measures focusing on these modifiable factors may decrease future COPD-related hospital admissions. The study design facilitated further explanation about factors that contributed to the persistent decrease in hospital admissions among people living with COPD and has underscored the importance of social support, patient empowerment and reduction in barriers in accessing care in admission reduction.

Home noninvasive ventilation use in patients hospitalized with COPD.

The study objective was to estimate the prevalence of chronic hypercapnic respiratory failure (CHRF) and home noninvasive ventilation (NIV) use in a high-risk population, individuals with a history of at least one COPD-related hospitalizations. We retrospectively analyzed electronic medical record data of patients with at least one COPD-related hospitalization between October 1, 2011, and September 30, 2017, to the Iowa City VA Medical Center. We excluded individuals with no obstructive ventilatory defect. Of 186 patients, the overall prevalence of compensated hypercapnic respiratory failure (CompHRF), defined as PaCO2 > 45 mmHg with a pH =7.35-7.45, was 52.7%, while the overall prevalence of home NIV was 4.3%. The prevalence of CompHRF was 43.6% and home NIV was 1.8% in those with one COPD-related hospitalization. Among those with ≥4 COPD-related hospitalizations, the prevalence of CompHRF was 77.8% (14 of 18), and home NIV was 11.1% (2 of 18). Approximately half of individuals with at least one COPD-related hospitalization have CompHRF, but only 8.2% of those use home NIV. Future studies should estimate CHRF rates and the degree of underutilization of home NIV in larger multicenter samples.

Pulmonary Rehabilitation in Persons With COPD.

Pulmonary rehabilitation (PR) is a high-value intervention for persons with COPD and other chronic lung diseases. It is associated with improvement in exercise capacity, dyspnea, health-related quality of life, and depression as well as a reduction in hospitalization and improved survival when PR follows COPD-related hospitalizations. PR is underused in the United States and other countries despite strong evidence of both clinical effectiveness and cost-effectiveness. Additional challenges include a lack of equitable reimbursement and poor access, particularly in rural settings. Models, for example, virtual PR, may be an option for improving access but coverage in the United States by Medicare is tenuous. In addition, virtual PR models have considerable heterogeneity, which challenges uniform efficacy and selection of optimal candidates.

Pharmacists' chronic disease management in chronic obstructive pulmonary disease: Effect on health services utilization.

BACKGROUND: There is limited real-world evidence on evaluation of chronic disease management initiatives provided by pharmacists to patients with chronic obstructive pulmonary disease (COPD). OBJECTIVE: To evaluate changes in COPD-related health care resource utilization between patients with COPD who had pharmacist-provided chronic disease management (comprehensive annual care plan [CACP]) vs those who did not have CACP. METHODS: Patients with COPD who received a CACP in Alberta between 2012 and 2015 were identified within the Alberta Health administrative data. Each of these patients were matched with 2 control patients with COPD based on age, sex, provider, date of service, and qualifying comorbidities. Controlled interrupted time series analysis was used to evaluate changes in COPD-specific hospitalizations, emergency department (ED) visits, physician visits, and claims for pulmonary function test. Immediate and temporal changes were calculated for the difference in outcomes 1 year before and 1 year after receiving the CACP for the intervention group and matched controls. RESULTS: Eligible patients (N = 74,365), of whom 28,795 (38.7%) had received CACPs, were matched to a total of 45,570 controls. In 1 year after the CACPs implementation, the number of COPD-related hospitalization visits decreased by 174 (95% CI = -270.8 to -76.5) per 10,000 patients per month, COPD-related ED visits decreased by 123 (95% CI = -294.9 to 49.6) per 10,000 per month, general practitioner visits decreased by 153.9 per 10,000 per month (95% CI = -293.3 to -14.5), and pulmonary function test claims decreased by 19.5 per 10,000 per month (95% CI = -70.1 to 31.2) when compared with the matched controls. However, significant difference between the 2 groups was found for COPD-related hospitalizations only, which was not confirmed by the sensitivity analysis. CONCLUSIONS: In patients with COPD who were provided with care plans by their community pharmacists, there was no significant decrease in COPD-related hospitalizations or ED visits over 1 year compared with the matched controls who did not have a pharmacist-provided care plan. Physician visits and pulmonary function tests did not change significantly for those who had CACP compared with those who did not. There is a need to further understand how care plans can better impact other outcomes that are important in COPD management. DISCLOSURES: This study was supported by a grant from the M.S.I. Foundation (Grant#895) based in Alberta, Canada. Dr Bhutani has consulted for Astra Zeneca, GlaxoSmithKline, Boehringer Ingelheim, Valeo, Covis, and Sanofi. The authors declare no other relevant conflicts of interest or financial relationships. This study is based on data provided by Alberta Health. The interpretation and conclusions of the results are those of the researchers and do not necessarily represent the views of the government of Alberta nor the funder (M.S.I. Foundation). All authors meet criteria for authorship as recommended by the International Committee of Medical Journal Editors.

The impact of the duration of the integrated disease management program on COPD-related outcomes

BackgroundThe aim of this study is to assess the impact of the duration of the integrated disease management (IDM) program on COPD-related outcomes in real-world setting.MethodsA retrospective cohort study among 3771 patients with COPD who had regularly completed 4 visits of IDM program within 1 year between April 1, 2017 and December 31, 2018. CAT score as the primary outcome used to investigate the association between IDM intervention duration and improvement in CAT score. Change in CAT score from baseline to each follow-up visit determined by using least-squares means (LSMeans) approach. The cut-off value of IDM duration for improving the CAT score was determined by the Youden index. Logistic regression was used to analyze the relationship between IDM intervention duration and MCID (the minimal clinically important difference) improvement in CAT score and the factor associated CAT improvement. Risks of COPD exacerbation events (COPD-related ED visit and COPD-related hospitalization) were estimated by using the cumulative incidence curve and Cox proportional hazards models.ResultAmong 3771 enrolled COPD patients, the majority of the study cohort were males (91.51%) and 42.7% of patients had CAT score of ≥ 10 at baseline. The mean of age was 71.47 years and the mean CAT at baseline were 10.49. The mean change from baseline in CAT score was − 0.87, − 1.19, − 1.23 and − 1.40 at 3-, 6-, 9- and 12 month follow-up (p < 0.0001 for all visits), respectively. Statistically significantly lower likelihood of achieving MCID improvement in CAT were observed at 3- and 6 month compared to 9 month (at 3 month: OR: 0.720, 95% CI 0.655–0.791; at 6 month: OR: 0.905, 95% CI 0.825–0.922). And only a modest increase likelihood of achieving MCID improvement in CAT at 12 month (OR: 1.097, 95% CI 1.001–1.201) compared with 9-month follow-up. In logistic regression on the entire cohort, CAT MCID improvement was most associated with baseline CAT scores ≥ 10, followed by frequent exacerbation in previous year (> 2 episodes/year), wheezing, and GOLD B or D at baseline. In baseline CAT ≥ 10 group, patients were more likely to achieve CAT MCID improvement and had greater decreases from baseline in CAT score observed at 3-, 6-, 9-, and 12 month compared with baseline CAT score < 10 group (all p < 0.0001). Moreover, in CAT ≥ 10 groups, patients who achieved CAT MCID improvement had lower risk of subsequent COPD exacerbation events (COPD-related ED visit: aHR: 1.196, 95% CI 0.985–1.453, p = 0.0713; COPD-related hospitalization: aHR: 1.529, 95% CI 1.215–1.924, p = 0.0003) when compared to those without.ConclusionThis is the first real-world study indicating the association between COPD IDM intervention duration and COPD-related outcomes. From 3 to 12 month follow-up results showed that continued improvement over time in COPD-specific health status, particularly in patients with baseline CAT score of ≥ 10. Furthermore, a reduction of the risk of subsequent COPD exacerbations were observed in patients with CAT MCID improvement.

Association of rural living with COPD-related hospitalizations and deaths in US veterans

It is unclear whether the high burden of COPD in rural areas is related to worse outcomes in patients with COPD or is because the prevalence of COPD is higher in rural areas. We assessed the association of rural living with acute exacerbations of COPD (AECOPDs)-related hospitalization and mortality. We retrospectively analyzed Veterans Affairs (VA) and Medicare data of a nationwide cohort of veterans with COPD aged ≥ 65 years with COPD diagnosis between 2011 and 2014 that had follow-up data until 2017. Patients were categorized based on residential location into urban, rural, and isolated rural. We used generalized linear and Cox proportional hazards models to assess the association of residential location with AECOPD-related hospitalizations and long-term mortality. Of 152,065 patients, 80,162 (52.7%) experienced at least one AECOPD-related hospitalization. After adjusting for demographics and comorbidities, rural living was associated with fewer hospitalizations (relative risk-RR = 0.90; 95% CI: 0.89–0.91; P < 0.001) but isolated rural living was not associated with hospitalizations. Only after accounting for travel time to the closest VA medical center, neighborhood disadvantage, and air quality, isolated rural living was associated with more AECOPD-related hospitalizations (RR = 1.07; 95% CI: 1.05–1.09; P < 0.001). Mortality did not vary between rural and urban living patients. Our findings suggest that other aspects than hospital care may be responsible for the excess of hospitalizations in isolated rural patients like poor access to appropriate outpatient care.

Inference of chronic obstructive pulmonary disease with deep learning on raw spirograms identifies new genetic loci and improves risk models.

Chronic obstructive pulmonary disease (COPD), the third leading cause of death worldwide, is highly heritable. While COPD is clinically defined by applying thresholds to summary measures of lung function, a quantitative liability score has more power to identify genetic signals. Here we train a deep convolutional neural network on noisy self-reported and International Classification of Diseases labels to predict COPD case-control status from high-dimensional raw spirograms and use the model's predictions as a liability score. The machine-learning-based (ML-based) liability score accurately discriminates COPD cases and controls, and predicts COPD-related hospitalization without any domain-specific knowledge. Moreover, the ML-based liability score is associated with overall survival and exacerbation events. A genome-wide association study on the ML-based liability score replicates existing COPD and lung function loci and also identifies 67 new loci. Lastly, our method provides a general framework to use ML methods and medical-record-based labels that does not require domain knowledge or expert curation to improve disease prediction and genomic discovery for drug design.

TCM as adjunctive therapy improves risks of respiratory hospitalizations in persons with type 2 diabetes: A retrospective cohort study.

Patients with type 2 diabetes are at a higher risk of chronic obstructive pulmonary disease (COPD) and asthma than the general population. In addition, emerging evidence suggests that traditional Chinese medicine (TCM) might be beneficial for patients with type 2 diabetes. We investigated whether TCM use was associated with a reduced risk of respiratory hospitalizations in patients with type 2 diabetes. Conducting a retrospective cohort study, we used data retrieved from the NDCMP database. Among 56,035 patients, 5226 were classified as TCM users; 50,809 were classified as TCM nonusers. Both groups were analyzed until the end of 2011 to examine the incidence of respiratory hospitalizations by using a Cox proportional hazards model to evaluate effects of TCM use on respiratory hospitalizations. During the 6-year study follow-up period, the incidence density rates of COPD- and asthma-related hospitalization were estimated to be 13.03 and 4.47 per 10,000 patient-years for TCM nonusers and 10.08 and 3.28 per 10,000 patient-years for TCM users, respectively. The HR of COPD-related hospitalization in TCM users was 0.88 (95% CI = 0.79-0.99); and the HR of asthma-related hospitalization in TCM users was 0.81 (95% CI = 0.66-1.00). Stratified analyses revealed that effects of TCM use were stronger among individuals who had diabetes for <3 years. As a part of Integrative Medicine, our study results demonstrate that TCM use was associated with a significant reduced risk of respiratory hospitalizations, especially in patients with diabetes for <3 years.