All Danish first-time COPD hospitalisations 2002–2008: Incidence, outcome, patients, and care

National Development in the Use of Inhaled Corticosteroid Treatment in Chronic Obstructive Pulmonary Disease: Repeated Cross-Sectional Studies from 1998 to 2018

Recommendations for the treatment of chronic obstructive pulmonary disease (COPD) have shifted towards a more restrictive use of inhaled corticosteroids (ICS). We aimed to identify the nationwide development over time in the use of ICS treatment in COPD. We conducted a register-based repeated cross-sectional study using Danish nationwide registers. On a yearly basis from 1998 to 2018, we included all patients in Denmark ≥ 40 years of age with an ICD-10 diagnosis of COPD (J44). Accumulated ICS use was calculated for each year based on redeemed prescriptions. Patients were divided into the following groups: No ICS, low-dose ICS, medium-dose ICS, or high-dose ICS. From 1998 to 2018, the yearly proportion of patients without ICS treatment increased (from 50.6% to 57.6%), the proportion of patients on low-dose ICS treatment increased (from 11.3% to 14.9%), and the proportion of patients on high-dose ICS treatment decreased (from 17.0% to 9.4%). We demonstrated a national reduction in the use of ICS treatment in COPD from 1998 to 2018, with an increase in the proportion of patients without ICS and on low-dose ICS treatment and a decrease in the proportion of patients on high-dose ICS treatment.

All-cause admissions following a first ever exacerbation-related hospitalisation in COPD

Background

Hospital admissions are important contributors to the overall burden of chronic obstructive pulmonary disease (COPD). Understanding the patterns and causes of hospital admissions will help to identify targets for preventive interventions. This study aimed to determine the 5-year all-cause hospital admission trajectories of patients with COPD following their first ever exacerbation-related hospitalisation.

Methods

Patients with COPD were identified from the Danish national registries. Patients experiencing their first ever exacerbation-related hospitalisation, defined as the index event, between 2000 and 2014 were included. All-cause hospital admissions were examined during a subsequent 5-year follow-up period, and categorised using the International Classification of Diseases, 10th revision.

Results

In total, 82 964 patients with COPD were included. The mean±sd age was 72±10 years and 48% were male. Comorbidities were present in 58%, and 65% of the patients collected inhalation medication ≤6 months prior to the index event. In total, 337 066 all-cause hospital admissions were identified, resulting in a 5-year admission rate of 82%. Most admissions were due to nonrespiratory causes (59%), amongst which cardiac events were most common (19%).

Conclusion

Hospital admissions following a first exacerbation-related hospitalisation are common; nonrespiratory events constitute the majority of admissions. Besides the respiratory causes, treatment targeting the nonrespiratory causes of hospital admission should be considered to effectively decrease the burden of hospitalisation in COPD.

A Revised Treatment Approach for Hospitalized Patients with Eosinophilic and Neutrophilic Exacerbations of Chronic Obstructive Pulmonary Disease

OBJECTIVES

The choice of treatment according to the inflammation type in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) has been of recent interest. This study investigated the role of novel biomarkers, hospital outcomes, and readmission rates in the first month in patients with eosinophilic or neutrophilic AECOPD.

MATERIALS AND METHODS

We conducted a retrospective observational cohort study in a Chest Teaching Hospital with hospitalized AECOPD patients. Subjects' characteristics, hemogram results, C-reactive protein (CRP), neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), platelet/mean platelet volume (PLT/MPV), length of hospital stay, mortality, and steroid use were recorded. Eosinophilic AECOPD defined as peripheral blood eosinophilia (PBE) was >2% and neutrophilic AECOPD as PBE ≤2%. Readmission within 28 days of discharge was recorded.

RESULTS

Of 2727(31.5% females) patients, eosinophilic AECOPD was found in 510 (18.7%) patients. Leucocytes, CRP, NLR, and PLR were significantly higher in neutrophilic AECOPD than in eosinophilic AECOPD (p<0.001). Steroid use and mortality rate were 45% and 0.6% in eosinophilic AECOPD and 71%, and 1.4% in neutrophilic AECOPD, respectively (p=0.001, p=0.19). Age >75 years, albumin <2.5 g/dL, CRP >50 mg/dL, and PLT/MPV <20×103 were found to be risks factors for hospital mortality (p<0.05 each). Readmission rates within 28 days of discharge were 5% (n=136), and this rate was higher in eosinophilic AECOPD patients not taking steroids (p<0.001).

CONCLUSION

NLR, PLR, and CRP levels were higher in neutrophilic AECOPD compared with eosinophilic AECOPD. These markers decreased with treatment in neutrophilic AECOPD. A PLT/MPV ratio of <20×103 resulted in an increased mortality rate. Thus, appropriate steroid therapy may reduce readmission rates in the first 28 days after discharge in eosinophilic AECOPD.

Prehospital prognosis is difficult in patients with acute exacerbation of chronic obstructive pulmonary disease

Background

Patients with acute exacerbation of chronic obstructive pulmonary disease often require prehospital emergency treatment. This enables patients who are less ill to be treated on-site and to avoid hospital admission, while severely ill patients can receive immediate ventilatory support in the form of intubation. The emergency physician faces difficult treatment decisions, however, and prognostic tools that could assist in determining which patients would benefit from intubation and ventilator support would be helpful. The aim of the current study was to identify prehospital clinical variables associated with mortality from acute exacerbation of chronic obstructive pulmonary disease. As part of the study, we estimated the 30-day mortality for patients with this prehospital diagnosis.

Methods

A retrospective study was performed using data collected by the mobile emergency care unit in Odense, Denmark, combined with data from the patients’ medical records. Patients with the tentative diagnosis of acute exacerbation of chronic obstructive pulmonary disease between 1st July 2011 and 31st December 2013 were included in the study.

Results

Based on data from 530 patients, we found no statistically significant associations between prehospital clinical variables and mortality, apart from a minor association between older age and higher mortality. The overall 30-day mortality was 10%, while that for patients admitted to the intensive care unit was 30%.

Conclusion

No specific prehospital prognostic factors for mortality were identified. Prognostic assessment and the decision to withhold treatment for acute exacerbation of chronic obstructive pulmonary disease seem inadvisable in the prehospital setting.

Trends in assisted ventilation and outcome for obstructive pulmonary disease exacerbations. A nationwide study

BACKGROUND

Non-invasive ventilation (NIV) has been used for decades in treatment of exacerbations of chronic obstructive pulmonary disease (COPD). The impact of the changing use of assisted ventilation in acute exacerbations on outcomes has not been fully elucidated and we aimed to describe these changes in the Danish population and describe their consequences for mortality.

METHODS

A register-based study was conducted of a cohort of 12,847 patients admitted for acute exacerbation of COPD (AECOPD) from 2004 through 2011, treated with invasive mechanical ventilation (IMV) or NIV for the first time. Age, sex, in-hospital mortality rates, time to death or readmission for AECOPD were established and changes over time tracked.

RESULTS

The number of admissions for AECOPD where assisted ventilation was used was 1,130 in 2004 and had increased by 145% in 2011. First time ventilations increased by 88%. This was mainly due to an increase in use of NIV accounting for 36% of the total number of assisted ventilations in 2004 and 67% in 2011. The number of IMV with or without NIV treatments remained constant. The mean age of NIV patients increased from 71.5 to 73.6 years, but remained constant at 70.0 years in IMV patients. Mortality rates both in hospital and after discharge for patients receiving NIV remained constant throughout the period. In-hospital mortality following IMV increased from 30% to 38%, but mortality after discharge remained stable.

CONCLUSION

Assisted ventilation has been increasingly used in a broader spectrum of AECOPD patients since the introduction of NIV. The changes in treatment strategies have been followed by shifts in in-hospital mortality rates following IMV.

Frequent coexistence of chronic heart failure and chronic obstructive pulmonary disease in respiratory and cardiac outpatients: Evidence from SUSPIRIUM, a multicentre Italian survey

Background Chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD) frequently coexist but concurrent COPD + CHF has been little investigated. Design This multicentre survey (SUSPIRIUM) was designed to evaluate: the prevalence of COPD in stable CHF and CHF in stable COPD; diagnostic/therapeutic work-up for concurrent COPD + CHF; clinical profile of patients with COPD + CHF; predictors of COPD in CHF and CHF in COPD. Methods A 5-month-long cross-sectional prospective observational survey was conducted in 10 cardiac and 10 respiratory connected outpatient units. Results The prevalence of CHF in the 378 surveyed COPD patients was 11.9% (95% confidence interval 8.8-16.6) and the prevalence of COPD in 375 CHF patients was 31.5% (95% confidence interval 26.8-36.4). Diagnostic tests for suspected comorbidity were prescribed in 21.6% and 22.9% of COPD and CHF patients, respectively. Patients with coexisting CHF + COPD had a higher incidence of hypertension, physical inactivity and more frequently a GOLD score of 3 or greater. Compared to CHF only, CHF + COPD patients were significantly older, more frequently smokers, at worse respiratory risk and in a higher New York Heart Association class. Conversely, hypercholesterolaemia, a family history of ischaemic heart disease, fluid retention and comorbidities were more frequent in COPD + CHF than COPD-only patients. At multivariate analysis, a GOLD score of 3 or greater in CHF strongly predicted coexistent COPD (odds ratio 8.985, P < 0.0001) as did a history of other respiratory diseases (5.184, P < 0.0001). A history of ischaemic heart disease (4.868, P < 0.0001), atrial fibrillation (3.302, P < 0.0001) and sedentary lifestyle (2.814, P < 0.004) predicted coexistent CHF in COPD. Conclusion The high prevalence of COPD + CHF calls for integrated disease management between cardiologists and pulmonologists. SUSPIRIUM identifies which cardiac/pulmonary outpatients should be screened for the respective comorbidity.

Chronic obstructive pulmonary disease in Denmark: Age-period-cohort analysis of first-time hospitalisations and deaths 1994-2012

BACKGROUND

During the 80s and 90s the mortality and number of hospitalisations due to chronic obstructive pulmonary disease (COPD) in the country of Denmark almost doubled. Since then there has been a plateau.

OBJECTIVE

To analyse age, period, and cohort effects on rates of deaths and first-time hospitalisations with COPD in Denmark during the period from 1994 to 2012 and to make a forecast of these parameters.

METHODS

By use of national registers, two separate age-period-cohort analyses were made, one on COPD-specific mortality rates and the other on incidence rates of first-time hospitalisations with COPD.

RESULTS

Both analyses found that high risk of developing severe COPD is associated with being born for women around year 1930 and for men around year 1925. The model has solid predictive ability and projections of future death- and hospitalisation rates due to COPD were made.

CONCLUSION

Long-term cohort effects rather than present exposure and treatment explain the recent rise and fall in the epidemic of COPD in Denmark. In the near future ageing of birth cohorts with lower COPD-specific mortality and hospitalisation rates will most likely lead to a substantial decrease in severe COPD in Denmark. However, rising trends for cohorts born after year 1948 calls for concern.

General practitioners' home visit tendency and readmission-free survival after COPD hospitalisation: a Danish nationwide cohort study

BACKGROUND

The tendency of general practitioners (GPs) to conduct home visits is considered an important aspect of practices' accessibility and quality of care.

AIMS

To investigate whether GPs' tendency to conduct home visits affects 30-day readmission or death after hospitalisation with chronic obstructive pulmonary disease.

METHODS

All Danish patients first-time hospitalised with COPD during the years 2006-2008 were identified. The association between the GP's tendency to conduct home visits and the time from hospital discharge until death or all-cause readmission was analysed by means of Cox regression adjusted for multiple patient and practice characteristics.

RESULTS

The study included 14,425 patients listed with 1,389 general practices. Approximately 31% of the patients received a home visit during the year preceding their first COPD hospitalisation, and within 30 days after discharge 19% had been readmitted and 1.6% had died without readmission. A U-shaped dose-response relationship was found between GP home visit tendency and readmission-free survival. The lowest adjusted risk of readmission or death was recorded among patients who were listed with a general practice in which >20-30% of other listed first-time COPD-hospitalised patients had received a home visit. The risk was higher if either 0% (hazard rate ratio 1.18 (1.01-1.37)) or >60% (hazard rate ratio 1.23 (1.04-1.44)) of the patients had been visited.

CONCLUSION

A moderate GP tendency to conduct home visits is associated with the lowest 30-day risk of COPD readmission or death. A GP's tendency to conduct home visits should not be used as a unidirectional indicator of the ability to prevent COPD hospital readmissions.

National trends in main causes of hospitalization: a multi-cohort register study of the finnish working-age population, 1976-2010

Background

The health transition theory argues that societal changes produce proportional changes in causes of disability and death. The aim of this study was to identify long-term changes in main causes of hospitalization in working-age population within a nation that has experienced considerable societal change.

Methodology

National trends in all-cause hospitalization and hospitalizations for the five main diagnostic categories were investigated in the data obtained from the Finnish Hospital Discharge Register. The seven-cohort sample covered the period from 1976 to 2010 and consisted of 3,769,356 randomly selected Finnish residents, each cohort representing 25% sample of population aged 18 to 64 years.

Principal Findings

Over the period of 35 years, the risk of hospitalization for cardiovascular diseases and respiratory diseases decreased. Hospitalization for musculoskeletal diseases increased whereas mental and behavioral hospitalizations slightly decreased. The risk of cancer hospitalization decreased marginally in men, whereas in women an upward trend was observed.

Conclusions/Significance

A considerable health transition related to hospitalizations and a shift in the utilization of health care services of working-age men and women took place in Finland between 1976 and 2010.

Heart failure and chronic obstructive pulmonary disease: the challenges facing physicians and health services

Pulmonary disease is common in patients with heart failure, through shared risk factors and pathophysiological mechanisms. Adverse pulmonary vascular remodelling and chronic systemic inflammation characterize both diseases. Concurrent chronic obstructive pulmonary disease presents diagnostic and therapeutic challenges, and is associated with increased morbidity and mortality. The cornerstones of therapy are beta-blockers and beta-agonists, whose pharmacological properties are diametrically opposed. Each disease is implicated in exacerbations of the other condition, greatly increasing hospitalizations and associated health care costs. Such multimorbidity is a key challenge for health-care systems oriented towards the treatment of individual diseases. Early identification and treatment of cardiopulmonary disease may alleviate this burden. However, diagnostic and therapeutic strategies require further validation in patients with both conditions.

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

OBJECTIVE

We aim to analyze changes in incidence, comorbidity profile, length of hospital stay (LOHS), costs and in-hospital mortality (IHM) of patients hospitalized for acute exacerbations of chronic obstructive pulmonary disease (AE-COPD) over a 5-year study period in Spain.

METHODS

We selected all hospital admissions for AE-COPD between 2006 and 2010 from the National Hospital Discharge Database covering the entire population of Spain.

RESULTS

We identified a total of 215,835 patients. Overall crude incidence had decreased from 2.9 to 2.4 exacerbations of COPD per 10,000 inhabitants from 2006 to 2010 (p < 0.001). In 2006, 17.9% of patients had a Charlson Index >2 and in 2010, the prevalence had increased to 25.0% (p < 0.001). Regarding to treatment, we detected a significant increase in the use of non-invasive ventilation from 2.1% in 2006 to 5.3% in 2010 (p < 0.001). The median LOHS was 7 days in 2006 and it remained stable until 2010. During the period studied, the mean cost per patient increased from 3747 to 4129 Euros. Multivariate analysis showed that incidence of hospitalizations for AE-COPD and IHM had significantly decreased from 2006 to 2010.

CONCLUSIONS

The current study provides data indicating a decrease in incidence of hospital admissions for AE-COPD in Spain from 2006 to 2010 with concomitant reduction in IHM, despite increasing comorbidity during this period, with no variations in LOHS. The mean cost per patient has risen significantly.

On the crest of a wave: Danish prevalence of hospitalisation-required COPD 2002-2009

OBJECTIVE

Symptoms, mortality, and costs of chronic obstructive pulmonary disease (COPD) concentrate among patients who have been hospitalised with the disease. Nevertheless, no solid estimates exist of trends in the prevalence of this condition. This study aimed to investigate age- and sex-specific trends in the prevalence of hospitalisation-required COPD.

METHOD

Using national registers, a cohort trend study was conducted covering the entire Danish population (5.4 million citizens) from 1994 to 2009. Subjects were classified as prevalent in the period between first COPD hospitalisation and either death, migration, or the end of an individual 8-year period with no COPD hospitalisations.

RESULTS

In 2009 in Denmark the prevalence of hospitalisation-required COPD was: For males 45-59 years 0.36%, 60-74 years 1.37%, 75-84 years 4.13%, 85+ years 4.33%, and for females: 45-59 years: 0.49%, 60-74 years: 1.74%, 75-84 years: 3.96%, 85+ years: 2.99%. During the period from 2002 to 2009 the overall prevalence remained constant. However, among subjects aged above and below 75 years, respectively, substantial decreases and increases were found. An increasing female prevalence exceeded male prevalence, which decreased.

CONCLUSION

Some 4% of the Danish population aged above 75 years have been hospitalised with COPD. During the period from 2002 to 2009 the overall prevalence of hospitalisation-required COPD remained constant. However, significant age-specific trends indicate that within a few years, ageing of birth cohorts with low COPD prevalence will lead to a substantial decrease in the prevalence of hospitalisation-required COPD.