Primary Diagnosis Of Chronic Obstructive Pulmonary Disease Research Articles

Inhaler Use in Hospitalized Patients with Chronic Obstructive Pulmonary Disease or Asthma: Assessment of Wasted Doses.

Hospitalized patients with chronic obstructive pulmonary disease (COPD) or asthma routinely have inhaled medications ordered for acute and maintenance therapy. Treatment may be administered via metered-dose inhaler (MDI) or dry-powder inhaler (DPI). These products must be appropriately labeled to be released home with the patient or discarded before discharge. To assess the amount and estimated cost of wasted doses of medications via MDI or DPI for hospitalized patients with COPD/asthma. A retrospective study was conducted at a university-affiliated hospital. Patients admitted between January 2011 and June 2012 with a primary diagnosis of COPD or COPD with asthma and who were ≥40 years of age were included. Information collected included use of albuterol, ipratropium, inhaled corticosteroids, long-acting beta agonist, or tiotropium and whether treatments were given by nebulizer, MDI, MDI plus valved holding chamber (VHC), or DPI. The number of doses dispensed, as well as doses not used, via MDI, MDI + VHC, or DPI were collected from electronic medical records. Costs associated with wasted medications were evaluated. Of 555 patient admissions screened, 478 (mean age, 66 years; 58% women; 74% African American) met study criteria. Of the total MDI or DPI doses dispensed, 87% were wasted, and associated hospital cost was approximately $86,973. Substantial waste of inhaled medications was found in our study. Practical strategies are needed to reduce wasted inhalers. Further assessment of this problem is needed in other US hospitals.

Impact of a countywide smoke-free workplace law on emergency department visits for respiratory diseases: a retrospective cohort study.

BackgroundWith the goal of reducing exposure to secondhand smoke, the state of Minnesota (MN), enacted a smoke-free law (i.e., Freedom to Breathe Act) in all workplaces, restaurants, and bars in 2007. This retrospective cohort study analyzes emergency department (ED) visits in Olmsted County, MN, for chronic obstructive pulmonary disease (COPD) and asthma over a five-year period to assess changes after enactment of the smoke-free law.MethodsWe calculated the rates of ED visits in Olmsted County, MN, with a primary diagnosis of COPD and asthma in the five-year period from January 1, 2005 to December 31, 2009. Analyses were performed using segmented Poisson regression to assess whether ED visit rates declined following enactment of the smoke free law after adjusting for potential underlying temporal trends in ED visit rates during this time period.ResultsUsing segmented Poisson regression analyses, a significant reduction was detected in asthma-related ED visits (RR 0.814, p < 0.001) but not for COPD-related ED visits following the enactment of the smoke-free law. The reduction in asthma related ED visits was observed in both adults (RR 0.840, p = 0.015) and children (RR 0.751, p = 0.015).ConclusionsIn Olmsted County, MN, asthma-related ED visits declined significantly after enactment of a smoke-free law. These results add to the body of literature supporting community health benefits of smoke-free policies in public environments and their potential to reduce health care costs.

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.

Time to adapt exercise training regimens in pulmonary rehabilitation--a review of the literature.

Exercise intolerance, exertional dyspnea, reduced health-related quality of life, and acute exacerbations are features characteristic of chronic obstructive pulmonary disease (COPD). Patients with a primary diagnosis of COPD often report comorbidities and other secondary manifestations, which diversifies the clinical presentation. Pulmonary rehabilitation that includes whole body exercise training is a critical part of management, and core programs involve endurance and resistance training for the upper and lower limbs. Improvement in maximal and submaximal exercise capacity, dyspnea, fatigue, health-related quality of life, and psychological symptoms are outcomes associated with exercise training in pulmonary rehabilitation, irrespective of the clinical state in which it is commenced. There may be benefits for the health care system as well as the individual patient, with fewer exacerbations and subsequent hospitalization reported with exercise training. The varying clinical profile of COPD may direct the need for modification to traditional training strategies for some patients. Interval training, one-legged cycling (partitioning) and non-linear periodized training appear to be equally or more effective than continuous training. Inspiratory muscle training may have a role as an adjunct to whole body training in selected patients. The benefits of balance training are also emerging. Strategies to ensure that health enhancing behaviors are adopted and maintained are essential. These may include training for an extended duration, alternative environments to undertake the initial program, maintenance programs following initial exercise training, program repetition, and incorporation of approaches to address behavioral change. This may be complemented by methods designed to maximize uptake and completion of a pulmonary rehabilitation program.

A retrospective study of the impact of a telephone alert service (Healthy Outlook) on hospital admissions for patients with chronic obstructive pulmonary disease.

Background:Healthy Outlook is a service delivered by the UK Met Office directly to patients with chronic obstructive pulmonary disease (COPD) that has been in place since 2006. Its objective is to reduce the severity and length of COPD exacerbations, hence improving the quality of life and life expectancy.Aims:To assess the effect of the Healthy Outlook service on hospital admission rates of all general practitioners that have used the service.Methods:Control practices were selected for each of the 661 participating practices. The number of hospital admissions for each practice was extracted from the Hospital Episode Statistics database. The differences in admission rates per practice between the first year of use of the Healthy Outlook service and the previous year were compared by paired t-test analyses.Results:For admissions with a primary diagnosis of COPD, the difference between participating and control practices was −0.8% (95% confidence interval (CI)=−1.8 to 0.2%; P=0.13). For admissions with a primary or co-morbid diagnosis of COPD, the difference was −2.3% (95% CI=−4.2 to −0.4%; P=0.02).Conclusions:Participation in the Healthy Outlook service reduces hospital admission rates for patients coded on discharge with COPD (including co-morbid).

Predictors for mortality in hospitalized patients with chronic obstructive pulmonary disease.

BackgroundChronic obstructive pulmonary disease (COPD) has been the only leading cause of death associated with a continuously increasing trend in the US over the past 30 years.ObjectivesThe aim of this research was to identify predictors for all-cause in-hospital mortality for COPD patients.MethodsWe conducted a cross-sectional study of patients with the discharge diagnosis of COPD, utilizing the 2007 Premier Perspective database. Inpatients aged 40 years and above were selected if they had a discharge with a primary diagnosis of COPD between January 1, 2007 and December 31, 2007. All data analyses were based on individual level. If a patient had multiple discharges, only the last discharge was included for mortality analysis. Predictors for mortality were identified by multiple logistic regressions. Bonferroni correction for multiple logistic regression models was adapted to control for family-wise errors.ResultsThe total of 57,224 patients was selected for data analysis in the study. All-cause in-hospital mortality for patients with COPD was 2.4%. Older age, insurance coverage, elective admission, intensive care unit admission, prolonged length of stay, increased Deyo-adapted Charlson Index (DCI) score and Elixhauser comorbidities of renal failure, metastatic cancer, solid tumor without metastasis, and weight loss were identified as independent predictors for all-cause in-hospital mortality. Antibiotics and β-blockers were predictors of lower all-cause in-hospital mortality risk after adjusting for other factors.ConclusionsThe nationwide discharge database provides useful information to identify predictors for all-cause in-hospital mortality of patients with COPD.Electronic supplementary materialThe online version of this article (doi:10.1186/2193-1801-3-359) contains supplementary material, which is available to authorized users.

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.

Inspiratory resistance decreases limb blood flow in COPD patients with heart failure

To the Editor: Chronic heart failure (CHF) with reduced left ventricular ejection fraction is a common and disabling comorbidity of chronic obstructive pulmonary disease (COPD) [1]. Understanding the mechanisms underlying exercise intolerance is paramount to providing a rationale to effectively rehabilitate the fast-growing population of patients with COPD plus CHF. The inspiratory muscles, in particular, are characteristically overloaded in COPD plus CHF, with greater elastic and resistive work of breathing. Moreover, these muscles might be functionally weakened as ventilation increases during exercise in patients with COPD [2]. It has been postulated that fatiguing contractions would stimulate diaphragmatic thinly myelinated group III and unmyelinated group IV fibres, thereby increasing limb sympathetic outflow and vascular resistance. The so-called respiratory muscle metaboreflex would then redirect blood flow from locomotor to respiratory muscles to avoid, or at least postpone, the impending failure of the “vital pump” [3, 4]. In this context, we previously found marked blood flow reduction to nonactive and active limbs during inspiratory resistive loading in CHF [5]. Work from our laboratory also showed improved peripheral muscle oxygen delivery after respiratory muscle unloading (under stable cardiac output and arterial oxygen content) in CHF-free COPD [6] and COPD-free CHF [7]. It is therefore conceivable that the coexistence of CHF would potentiate the respiratory muscle metaboreflex in patients with a primary diagnosis of COPD. After giving informed consent, 22 optimally treated patients with moderate-to-severe (Global Initiative for Chronic Obstructive Lung Disease stage II–III) COPD (10 with coexistent CHF, i.e. left ventricular ejection fraction <45% by echocardiography) and 10 age- and sex-matched controls underwent a ramp-incremental exercise test for …

Frequency of referral to and attendance at a pulmonary rehabilitation programme amongst patients admitted to a tertiary hospital with chronic obstructive pulmonary disease

Pulmonary rehabilitation (PR) is recommended in the management of people with chronic obstructive pulmonary disease (COPD), but implementation appears to be low. The aim of this study was to determine the frequency of referral to, and attendance at, PR programmes in a sample of patients with COPD. A cross-sectional study of patients admitted to a tertiary hospital in South Australia, with a primary diagnosis of COPD between March and November 2011 was conducted. Data were collected from medical records and patient interview. From 235 admissions with preliminary coding as COPD, 88 patients had COPD as the primary reason for admission and were potentially eligible for rehabilitation. While 57% had been referred to rehabilitation during their disease course, only 18% had attended and completed at least half the programme. Seven patients had attended in the previous 2 years. Mean percentage predicted forced expiratory volume in 1 s was 42% at the time of referral. During the index admission, discussion of rehabilitation resulting in a referral occurred in 14 cases (16%). No demographic or disease characteristics were associated with referral/no referral; being reviewed by a COPD nurse coordinator during admission increased the likelihood of referral (odds ratio = 18.7, 95% confidence interval: 3.8-91.4). PR had been implemented in a small proportion of patients admitted to hospital with an exacerbation of COPD due to gaps in both referral to and subsequent attendance at a programme. Strategies to improve referral to and participation in PR are required.

Predicting Chronic Obstructive Pulmonary Disease Hospitalizations Based on Concurrent Influenza Activity

Although influenza has been associated with chronic obstructive pulmonary disease (COPD) exacerbations, it is not clear the extent to which this association affects healthcare use in the United States. The first goal of this project was to determine to what extent the incidence of COPD hospitalizations is associated with seasonal influenza. Second, as a natural experiment, we used influenza activity to help predict COPD admissions during the 2009 H1N1 influenza pandemic. To do this, we identified all hospitalizations between 1998 and 2010 in the Nationwide Inpatient Sample from the Healthcare Cost and Utilization Project (HCUP) during which a primary diagnosis of COPD was recorded. Separately, we identified all hospitalizations during which a diagnosis of influenza was recorded. We formulated time series regression models to investigate the association of monthly COPD admissions with influenza incidence. Finally, we applied these models, fit using 1998–2008 data, to forecast monthly COPD admissions during the 2009 pandemic. Based on time series regression models, a strong, significant association exists between concurrent influenza activity and incidence of COPD hospitalizations (p-value < 0.0001). The association is especially strong among older patients requiring mechanical ventilation. Use of influenza data to predict COPD admissions during the 2009 H1N1 pandemic reduced the mean-squared prediction error by 29.9%. We conclude that influenza activity is significantly associated with COPD hospitalizations in the United States and influenza activity can be exploited to more accurately forecast COPD admissions. Our results suggest that improvements in influenza surveillance, prevention, and treatment may decrease hospitalizations of patients diagnosed with COPD.

Risk assessment of readmissions following an initial COPD-related hospitalization

BackgroundAcute exacerbation of chronic obstructive pulmonary disease (COPD) is a leading cause of hospitalizations and readmissions in the US. Reducing the frequency of hospital readmission is a high priority of US health care organizations and government agencies. This study evaluated the risk factors associated with readmissions among commercially insured adults aged 40–65 years in the US who were hospitalized for COPD.MethodsThis retrospective cohort study used anonymized claims data from the Truven Health MarketScan® Commercial Claims and Encounters database. The patients included were aged 40–65 years, had an index hospitalization with a primary diagnosis of COPD between July 1, 2008 and June 30, 2010 (continuously enrolled 12 months before and after), and were alive at hospital discharge. Patients with cystic fibrosis or tuberculosis or who were transferred to another inpatient facility after hospital discharge were excluded. All readmissions regardless of diagnosis, and separately a subset of all readmissions that had COPD as a primary or secondary diagnosis (COPD-related), were examined. Univariate descriptive statistics and multivariable regression methods were used.ResultsOf the 18,568 patients with index COPD hospitalizations, 6,095 (32.83%) met the eligibility criteria. Of those, 503 (8.25%) were readmitted within the first 30 days post-index hospitalization and 2,527 (41.46%) within the first year (COPD-related 340 [5.58%] and 1,681 [27.58%], respectively). The median time to the first readmission post initial discharge was 4.0 months, with a mean of 5.0 ± 3.4 months. Multivariable regression analyses showed that comorbid conditions and health care utilization in the pre-index period were significant predictors for readmission both 30 and 90 days following index hospitalization.ConclusionA relatively high readmission rate was observed for patients aged 40–65 years. The results suggest that attention to patient comorbidities and pre-index/index health care service utilization may help identify hospitalized COPD patients at higher risk for readmission.

675 Severity of Pulmonary Hypertension Predicts Short Term Lung Transplantation Outcomes in Subjects with Chronic Obstructive Pulmonary Disease

Purpose: Pulmonary hypertension (PH) is a common complication of chronic obstructive pulmonary disease (COPD), which is usually of mild severity. Whether PH severity in COPD subjects bears upon clinical outcomes following lung transplantation is not clear. We seek to determine whether echocardiography-based PH severity at time of lung transplant assessment predicts inferior short and long term outcomes post lung transplantation. Methods and Materials: Retrospective analysis including all lung transplant recipients at The Alfred between 2000 and 2009 for a primary diagnosis of COPD who underwent echocardiography at The Alfred. Only patients with a documented right ventricular systolic pressure (RVSP) were included. Patients were allocated into three groups based on their RVSP: No PH if RVSP 35 mmHg; Mild PH if 35 RVSP 45 mmHg; and Moderate-Severe PH if RVSP 45 mmHg. Outcome measures were ICU length of stay, time until extubation and PaO2/fraction inspired oxygen (PaO2/FiO2) ratio at 24 hours. Survival was measured at 30 days, 12 months, 5 years and overall. Results: Of 138 COPD lung transplant patients, 94 (68%) underwent echocardiography at The Alfred and 46 (33%) had documented RVSP. There were no differences in baseline demographics, pulmonary function, blood gases or cardiac function between the three PH groups. ModerateSevere PH predicted increased time until extubation (p 0.05), worse PaO2/FiO2 ratio at 24 hours (p 0.05), worse 12 month survival (p 0.05) and a trend toward increased ICU length of stay (p 0.06). We did not observe any significant differences between the groups for 30 day, 5 year or overall survival. RVSP was significantly correlated with ICU length of stay (r 0.513, p 0.001) and time until extubation (r 0.586, p 0.0001). Conclusions: PH severity predicts short term outcomes post lung transplantation in COPD subjects. The mechanisms through which COPD subjects with moderate-severe PH have inferior clinical outcomes following lung transplantation are yet to be elucidated.

Cardiovascular Events Associated with Ipratropium Bromide in COPD

In this large cohort study of 82,717 U.S. veterans with a new diagnosis of chronic obstructive pulmonary disease (COPD) in both the inpatient and outpatient setting, the authors evaluated the incidence of cardiovascular events (CVE) in patients exposed to inhaled anticholinergics (almost exclusively ipratropium bromide). A CVE was defined as a hospital admission for acute coronary syndrome, dysrhythmia, or heart failure. The cohort included U.S. veterans aged 40–100 years admitted to a Veterans Affairs (VA) hospital or seen in an outpatient clinic between October 1998 and September 2002 with a new primary diagnosis of COPD.

The Association Between Depressive Symptoms and Acute Exacerbations of COPD

Depression is an important comorbidity for patients with chronic obstructive pulmonary disease (COPD). The association between depression and acute exacerbations of COPD is unknown. This study was designed to determine the frequency of COPD exacerbations in outpatients with and without depressive symptoms. In this retrospective cohort study, patients with a primary diagnosis of COPD were followed for 1 year after discharge from a pulmonary rehabilitation program and the frequency of exacerbations was recorded. Upon completion of the program, all patients were administered the Short-Form 36 Health Survey (SF-36), which contains a mental health domain. Patients were classified as having depressive symptoms based on their domain score, which was separately validated in a second population of patients. Of the 194 patients with COPD who completed the pulmonary rehabilitation program, 32 (16.5%) had depressive symptoms. There were no differences in terms of age, race, pack-years, forced expiratory volume in 1 second (FEV(1)), 6-minute walk distance, body mass index, use of supplemental oxygen, use of inhaled steroids, or the Charlson Comorbidity Index between patients with and without depressive symptoms. Patients with depressive symptoms had more exacerbations in the following year (1.91 vs. 1.36; p = 0.02), were 2.8 times more likely to have ever had an exacerbation (95% confidence interval (CI), 1.1-7.3; p = 0.03), and suffered a first exacerbation earlier (148 days compared with 266 days; p = 0.04) than nondepressed patients. COPD patients with depressive symptoms have a significantly higher risk for exacerbations. Early screening for depression in patients with COPD may help identify those patients at higher risk for subsequent exacerbations.

Spirometry Utilization After Hospitalization for Patients With Chronic Obstructive Pulmonary Disease Exacerbations

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality in the US population. An area of improvement hinges on early detection and proper monitoring. Spirometry is an important interventional tool; its underuse among hospitalized patients with COPD could affect quality of care. This study evaluates spirometry use at the Community Medical Center-Sierra in hospitalized patients with COPD. A retrospective medical record review from January 1, 2000, to March 15, 2002, assesses 1507 inpatients with COPD. The effects are analyzed of age, sex, race/ethnicity, diagnosis, insurance status, disposition, and admitting service on spirometry use by physicians are analyzed. A questionnaire is used to evaluate the knowledge, attitudes, and behaviors of residents toward spirometry ordering. Baseline characteristics are similar between study groups. Only 3% of 1476 study patients have spirometry performed within the recommended time frame, and only 12.2% have at least 1 spirometry performed. Patients having a primary diagnosis of COPD have a greater likelihood of having spirometry performed (20.3% vs 11.1%, P < .001), as do patients who are discharged to home (13.4% vs 5.9%, P = .001). No significant effects are noted for sex, race/ethnicity, insurance status, or admitting service. The house staff surveys reveal that most do not know the indications for (72.0%) or how to order (46.0%) spirometry. Spirometry is underused among physicians who treat hospitalized patients with COPD. Future educational efforts aimed at improving physicians' ordering and use of spirometry are needed to address this disparity.

PULMONARY FUNCTION TEST UTILIZATION AFTER HOSPITALIZATION IN PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE.

Background Chronic obstructive pulmonary disease (COPD) is one of the leading causes of morbidity and mortality in the US population. One area of improvement hinges on early detection and proper monitoring. Pulmonary function testing is an important interventional tool; thus, its underutilization among hospitalized COPD patients could affect the quality of care. Objective To evaluate the pulmonary function test (PFT) utilization of primary care providers at the Community Medical Centers in hospitalized COPD patients. Methods We conducted a retrospective chart review of hospitalized COPD patients from January 1, 2000 to March 15, 2002, on 1,507 inpatients. We analyzed the effect of age, gender, race, diagnosis, insurance type, disposition, and admitting service on PFT utilization by physicians. A questionnaire was used to evaluate the knowledge, attitudes, and behaviors of the residents toward PFT ordering. Results Baseline characteristics were similar between study groups. Only 3% of the 1,476 study patients had PFTs in the recommended time frame, and only 12.2% had at least one PFT. Patients with a primary diagnosis of COPD had more PFTs completed (34.4% vs 11.1%; p = .0005). PFT testing varied between services (p = .003), although the number of patients was different. Patient insurance groups corresponded with differences in PFT utilization (p = .004). No significant differences were found with gender, ethnicity, or disposition. The housestaff survey forms revealed that the majority did not know the indications of (72%) or how to appropriately order (46%) PFTs. Conclusions PFT is underutilized among physicians who treat hospitalized COPD patients. Future educational efforts aimed in improving physicians9 ordering and utilization reviews are needed to address this disparity.

The Effect of Fine Particulate Air Matter on Emergency Admissions For Copd and Pneumonia: a Multi-City Case-Crossover Analysis

P-078 Introduction: While many studies have examined the effects of air pollution on mortality, fewer studies have examined hospital admissions for pneumonia and COPD, and generally in smaller multi-city or single city studies. In addition, PM2.5 data has only recently been available. Method: We conducted a multi-city case-crossover study of the acute effect of PM2.5 on the increased risk of being admitted to the hospital among the elderly in thirty-nine US cities with 451,000 admissions for pneumonia and 234,000 admissions for chronic obstructive pulmonary disease (COPD). We examined the association between daily fine particulate air matter (PM2.5) and Medicare data (age ge 65) on hospital admissions from the emergency room with a primary diagnosis of COPD (ICD-9: 490–496, except 493) and pneumonia (ICD-9: 480–487), in those cities for the years 1999–2003. In the first stage of the analysis, we applied a case-crossover design in each city with referent exposure days chosen using the time-stratified approach, with control days matched on year, month, and temperature to control possible residual confounding by weather. In the second stage of the analysis we combined the city-specific estimates using a random effect approach. Results: For COPD we found the higher effect at lag 1 with an increase of 1.17% (95% CI: 0.3%, 2.0%) for a 10 μg/m3 increase in PM2.5. We found a 1.51% increase (95% CI: 0.5%, 2.6%) in risk of admissions for pneumonia and PM2.5 two days before. Matching on every third day yielded similar results. Discussion and Conclusion: We conclude that our analysis showed an increased risk of hospitalization for COPD and pneumonia associated with PM2.5 among the elderly. More studies are needed to understand the biological mechanism and to examine effect modification.

MULTIDISCIPLINARY PAIN ABSTRACTS: 46 . Physical Medicine and Rehabilitation (46)

The aim of this study was to describe an association between the syndromes of lumbar spinal stenosis and chronic obstructive pulmonary disease (COPD) in patients presenting with symptoms of nocturnal lumbosacral radiculopathy. The study design was a retrospective review of 46 sequential inpatients referred with complaints of lumbosacral radicular pain associated with lumbar spinal stenosis. Half (23) were experiencing sleep disruptive nocturnal pain. Each had been hospitalized with a primary diagnosis of COPD. They were subsequently compared with another group of inpatients (23) who were also experiencing lumbar pain not necessarily increased at night. Each was also identified as having lumbar spinal stenosis without an antecedent history of COPD. In each case, lumbar spinal imaging studies (computed tomography or magnetic resonance imaging) were obtained. Pulmonary function tests were performed in those with COPD, and two‐dimensional echocardiograms were obtained in all 46 patients. The ratio of women to men, their ages, surgical interventions, severity of lumbar spinal stenosis, and left ventricular function as compared one group with another was not significantly different. However, pulmonary artery pressures were notably elevated in those with COPD and nocturnal lumbosacral radiculopathy. This study suggests that in patients with COPD and lumbar spinal stenosis, pulmonary hypertension may be the dynamic link exacerbating nocturnal lumbosacral pain.