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Bamonti PM, Fischer I, Moye J, Poghosyan H, Pietrzak RH. Obstructive respiratory disease in U.S. veterans: Prevalence, characteristics, and health burden. J Psychiatr Res 2024; 176:140-147. [PMID: 38857555 DOI: 10.1016/j.jpsychires.2024.05.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 05/15/2024] [Accepted: 05/29/2024] [Indexed: 06/12/2024]
Abstract
OBJECTIVE To examine the psychiatric and physical health burden of obstructive respiratory disease in a nationally representative sample of U.S. Veterans. METHODS Secondary data analyses were conducted using data from the 2019-2020 National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of U.S. Veterans. Participants self-reported health professional-diagnosed obstructive respiratory disease (i.e., asthma, chronic bronchitis or chronic obstructive pulmonary disease). Veterans who reported obstructive respiratory disease (n = 502) were compared to veterans without this disease but with at least one or more other medical conditions-controls (n = 3169) on measures of sociodemographic, trauma, psychiatric, and physical health characteristics. Multivariable regression analyses examined independent associations between obstructive respiratory disease and psychiatric conditions and physical characteristics. RESULTS A total 12.5% of the sample reported a diagnosis of obstructive respiratory disease. Compared to controls, veterans with obstructive respiratory disease were more likely to be female, unmarried/partnered, lower income, residing in the Midwest, receiving VA healthcare, and had greater lifetime and childhood trauma burden. In adjusted analyses, veterans with respiratory disease had 47-91% greater odds of screening positive for current posttraumatic stress, major depressive, and generalized anxiety disorders, and had 48% greater odds of current suicide ideation. They were also more likely to have lifetime nicotine use disorder and had more medical comorbidities and more severe somatic symptoms. CONCLUSIONS Obstructive respiratory disease is prevalent among U.S. veterans and associated with significant mental and physical health burden. Results highlight the need for timely screening and treatment for psychiatric and medical conditions that are highly comorbid with obstructive respiratory disease in this population.
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Affiliation(s)
- Patricia M Bamonti
- Research & Development, VA Boston Healthcare System, 150 S. Huntington Avenue, Boston, MA, USA; Department of Psychiatry, Harvard Medical School, 2 West, Room 305, 401 Park Drive, Boston, MA, 02215, USA.
| | - Ian Fischer
- National Center for PTSD, VA Connecticut Healthcare System, 950 Campbell Avenue, Connecticut, CT, 06516, USA; Department of Psychiatry, Yale School of Medicine, 300 George Street Ste 901, New Haven, CT, 06510, USA
| | - Jennifer Moye
- Department of Psychiatry, Harvard Medical School, 2 West, Room 305, 401 Park Drive, Boston, MA, 02215, USA; New England Geriatric Research Education & Clinical Center, VA Boston Healthcare System, 150 S. Huntington Avenue, Boston, MA, 02130, USA
| | - Hermine Poghosyan
- Yale School of Nursing, Orange, CT, 06477, USA; Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, CT, 06510, USA
| | - Robert H Pietrzak
- National Center for PTSD, VA Connecticut Healthcare System, 950 Campbell Avenue, Connecticut, CT, 06516, USA; Department of Psychiatry, Yale School of Medicine, 300 George Street Ste 901, New Haven, CT, 06510, USA; Department of Social and Behavioral Sciences, Yale School of Public Health, 60 College Street, New Haven, CT, 06510, USA
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Fortis S, Gao Y, Kaboli PJ, Vaughan Sarrazin M. Risk of Chronic Obstructive Pulmonary Disease (COPD) Hospitalizations and Deaths among Rural and Urban Veterans after Successive COPD Hospitalizations. Ann Am Thorac Soc 2024; 21:523-526. [PMID: 38134432 DOI: 10.1513/annalsats.202306-575rl] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 12/21/2023] [Indexed: 12/24/2023] Open
Affiliation(s)
- Spyridon Fortis
- Iowa City Veterans Affairs Healthcare System Iowa City, Iowa
- University of Iowa Roy J. and Lucille A. Carver College of Medicine Iowa City, Iowa
| | - Yubo Gao
- Iowa City Veterans Affairs Healthcare System Iowa City, Iowa
- University of Iowa Roy J. and Lucille A. Carver College of Medicine Iowa City, Iowa
| | - Peter J Kaboli
- Iowa City Veterans Affairs Healthcare System Iowa City, Iowa
- University of Iowa Roy J. and Lucille A. Carver College of Medicine Iowa City, Iowa
| | - Mary Vaughan Sarrazin
- Iowa City Veterans Affairs Healthcare System Iowa City, Iowa
- University of Iowa Roy J. and Lucille A. Carver College of Medicine Iowa City, Iowa
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Dursa EK, Cao G, Culpepper WJ, Schneiderman A. Comparison of Health Outcomes Over Time Among Women 1990-1991 Gulf War Veterans, Women 1990-1991 Gulf Era Veterans, and Women in the U.S. General Population. Womens Health Issues 2023; 33:643-651. [PMID: 37495424 DOI: 10.1016/j.whi.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 06/15/2023] [Accepted: 06/16/2023] [Indexed: 07/28/2023]
Abstract
INTRODUCTION The aim of this study is to examine health over almost 20 years of follow-up among women Gulf War veterans and women Gulf Era veterans and compare their health to that of women in the U.S. general population. METHODS We used data from a health survey of 1,274 women Gulf War veteran and Gulf Era veteran participants of the Gulf War Longitudinal Study who responded to all three waves. Data on the U.S. population of women came from the 1999-2000, 2005-2006, and 2011-2014 National Health and Nutrition Examination Survey (NHANES). Generalized estimating equations (GEEs) were used to compare the report of disease over time in women Gulf War and Gulf Era veterans. Differences in prevalence at the three survey timepoints were calculated between women Gulf War veterans and the NHANES women population, and women Gulf War Era veterans and the NHANES women population. RESULTS Women veterans who deployed to the 1990-1991 Gulf War report poorer health than women veterans who served during the same time but did not deploy. Women veterans reported a lower prevalence of hypertension, stroke, and diabetes than women in the NHANES sample. Women veterans also reported a higher prevalence of arthritis, chronic obstructive pulmonary disease, and skin cancer than women in the NHANES sample. CONCLUSIONS This study is the first to characterize the health of a population-based cohort of women Gulf War and women Gulf Era veterans over time and compare it with women's health in a civilian NHANES population. This demonstrates the value of epidemiological research on women veterans and the importance of developing longitudinal cohorts across genders.
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Affiliation(s)
- Erin K Dursa
- Health Outcomes Military Exposures, U.S. Department of Veterans Affairs, Washington, District of Columbia; Hines VA Medical Center Cooperative Studies Coordinating Center, Hines, Illinois.
| | - Guichan Cao
- Hines VA Medical Center Cooperative Studies Coordinating Center, Hines, Illinois
| | - William J Culpepper
- Health Outcomes Military Exposures, U.S. Department of Veterans Affairs, Washington, District of Columbia
| | - Aaron Schneiderman
- Health Outcomes Military Exposures, U.S. Department of Veterans Affairs, Washington, District of Columbia
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Fortis S, Gao Y, Baldomero AK, Sarrazin MV, Kaboli PJ. Association of rural living with COPD-related hospitalizations and deaths in US veterans. Sci Rep 2023; 13:7887. [PMID: 37193770 DOI: 10.1038/s41598-023-34865-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 05/09/2023] [Indexed: 05/18/2023] Open
Abstract
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.
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Affiliation(s)
- Spyridon Fortis
- Veterans Rural Health Resource Center-Iowa City, VA Office of Rural Health, and Center for Access and Delivery Research and Evaluation (CADRE) at the Iowa City VA Healthcare System, Iowa City, IA, USA.
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Occupational Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA.
| | - Yubo Gao
- Veterans Rural Health Resource Center-Iowa City, VA Office of Rural Health, and Center for Access and Delivery Research and Evaluation (CADRE) at the Iowa City VA Healthcare System, Iowa City, IA, USA
- Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Arianne K Baldomero
- Minneapolis VA Health Care System US, Minneapolis, MN, USA
- Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Mary Vaughan Sarrazin
- Veterans Rural Health Resource Center-Iowa City, VA Office of Rural Health, and Center for Access and Delivery Research and Evaluation (CADRE) at the Iowa City VA Healthcare System, Iowa City, IA, USA
- Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Peter J Kaboli
- Veterans Rural Health Resource Center-Iowa City, VA Office of Rural Health, and Center for Access and Delivery Research and Evaluation (CADRE) at the Iowa City VA Healthcare System, Iowa City, IA, USA
- Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
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Luyster FS, Boudreaux-Kelly MY, Bon JM. Insomnia in chronic obstructive pulmonary disease and associations with healthcare utilization and costs. Respir Res 2023; 24:93. [PMID: 36964552 PMCID: PMC10039604 DOI: 10.1186/s12931-023-02401-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 03/16/2023] [Indexed: 03/26/2023] Open
Abstract
Insomnia has been linked to adverse chronic obstructive pulmonary disease (COPD) outcomes including exacerbations, yet its impact on COPD-related healthcare utilization and costs is unknown. In this study, we investigated the associations between insomnia and healthcare utilization and costs in patients with COPD. A retrospective cohort of veterans with COPD were identified from national Veterans Affairs administration data for fiscal years 2012-2017. Insomnia was operationalized as having an insomnia diagnosis based on International Classification of Disease codes or having a prescription of > 30 doses of a sedative-hypnotic medication in a given fiscal year. The index date for insomnia was the first date when dual criteria for COPD and insomnia was met. The index date for those without insomnia was set as the COPD index date. Our primary outcomes were 1-year healthcare utilization and costs related to outpatient visits and hospitalizations after index date. COPD-related healthcare utilization variables included number of prescription fills of corticosteroids and/or antibiotics and outpatient visits and hospitalizations with a primary diagnosis of COPD. Out of 1,011,646 patients (96% men, mean age 68.4 years) diagnosed with COPD, 407,363 (38.8%) had insomnia. After adjustment for confounders, insomnia was associated with higher rates of outpatient visits, hospitalizations, and fills for corticosteroids and/or antibiotics, longer hospital length of stay, and $10,344 higher hospitalization costs in the 12 months after index date. These findings highlight the importance of insomnia as a potentially modifiable target for reducing the burden of COPD on patients and healthcare systems.
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Affiliation(s)
- Faith S Luyster
- School of Nursing, University of Pittsburgh, 3500 Victoria St, 415 Victoria Building, Pittsburgh, PA, 15241, USA.
- VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.
| | | | - Jessica M Bon
- VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, School of Medicine, Pittsburgh, PA, USA
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Archontakis Barakakis P, Tran T, You JY, Hernandez Romero GJ, Gidwani V, Martinez FJ, Fortis S. High versus Medium Dose of Inhaled Corticosteroid in Chronic Obstructive Lung Disease: A Systematic Review and Meta-Analysis. Int J Chron Obstruct Pulmon Dis 2023; 18:469-482. [PMID: 37056683 PMCID: PMC10086393 DOI: 10.2147/copd.s401736] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 03/27/2023] [Indexed: 04/15/2023] Open
Abstract
Background Inhaled corticosteroids (ICSs) combined with bronchodilators have been identified to improve outcomes in COPD but also to be associated with certain adverse effects. Objective We performed a systematic review and meta-analysis to compile and summarize data on the efficacy and safety of dosing levels (high versus medium/low) of ICS alongside ancillary bronchodilators following PRISMA guidelines. Data Sources Medline and Embase were systematically searched until December 2021. Randomized, clinical trials (RCTs) that met predefined inclusion criteria were included. Data Extraction Risk ratios (RRs) with 95% confidence intervals (CI) were extracted. Any acute exacerbation of COPD (AECOPD) risk was chosen as the primary efficacy outcome, mortality rate as the primary safety outcome, moderate/severe AECOPD risk as the secondary efficacy outcome and pneumonia risk as the secondary safety outcome. Subgroup analyses of individual ICS agents, of patients with baseline moderate/severe/very severe COPD and of patients with recent COPD exacerbation history were also performed. A random-effects model was used. Results We included 13 RCTs in our study. No data on low doses were included in the analysis. High dose ICS was not associated with a statistically significant difference in any AECOPD risk (RR: 0.98, 95% CI: 0.91-1.05, I2: 41.3%), mortality rate (RR: 0.99, 95% CI: 0.75-1.32, I2: 0.0%), moderate/severe AECOPD risk (RR: 1.01, 95% CI: 0.96-1.06, I2: 0.0%) or pneumonia risk (RR: 1.07, 95% CI: 0.86 -1.33, I2: 9.3%) compared to medium dose ICS. The same trend was identified with the several subgroup analyses. Conclusion Our study collected RCTs investigating the optimal dosing level of ICS prescribed alongside ancillary bronchodilators to patients with COPD. We identified that the high ICS dose neither reduces AECOPD risk and mortality rates nor increases pneumonia risk relative to the medium dose.
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Affiliation(s)
- Paraschos Archontakis Barakakis
- Northeast Internal Medicine Associates, LaGrange, IN, USA
- Correspondence: Paraschos Archontakis Barakakis, Northeast Internal Medicine Associates, 4344 Love Grass Lane, Fort Wayne, LaGrange, IN, 46845, USA, Tel +1 929-422-4589, Email
| | - Thuonghien Tran
- Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Jee Young You
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Vipul Gidwani
- Northeast Internal Medicine Associates, LaGrange, IN, USA
| | - Fernando J Martinez
- Departments of Medicine and Genetic Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Spyridon Fortis
- Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
- Veterans Rural Health Resource Center, VA Office of Rural Health, and Center for Access and Delivery Research and Evaluation (CADRE) at the Iowa City VA Healthcare System, Iowa City, IA, USA
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Buhl R, Wilke T, Picker N, Schmidt O, Hechtner M, Kondla A, Maywald U, Vogelmeier CF. Real-World Treatment of Patients Newly Diagnosed with Chronic Obstructive Pulmonary Disease: A Retrospective German Claims Data Analysis. Int J Chron Obstruct Pulmon Dis 2022; 17:2355-2367. [PMID: 36172035 PMCID: PMC9512029 DOI: 10.2147/copd.s375190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 08/21/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose This study aimed to describe the real-world treatment of German incident COPD patients, compare that treatment with clinical guidelines, and provide insight into disease development after incident diagnosis. In addition, the economic burden of the disease by assessing COPD-related healthcare costs was described. Patients and Methods Based on a German claims dataset, continuously insured individuals (04/2014-03/2019) aged 40 years or older with at least two incident pulmonologist's diagnoses or one inpatient diagnosis of COPD (ICD-10-GM code J44.-; no respective diagnosis in a 12-month baseline period) were selected. Treatment patterns after incident diagnosis considering inhaled maintenance therapies identified by ATC codes (outpatient prescriptions) were analyzed. Prescription patterns were compared with recommendations of German COPD treatment guidelines. Severe exacerbations were assessed as hospitalizations with main diagnosis ICD-10-GM code J44.1. COPD-associated costs from the perspective of the health insurance fund AOK PLUS were calculated per patient-year (PY). Results The sample comprised 17,464 incident COPD patients with a mean age of 71.5 years. 58.9% were male and the mean Charlson-Comorbidity-Index was 5.3. During follow-up (median: 2.0 years), 57.1% of the patients received at least one prescription of an inhaled maintenance therapy, whereas 42.9% did not. Among treated patients, 35.2% started their treatment with LABA/LAMA, 25.3% with LAMA monotherapy, 16.2% with LABA/ICS, and 7.8% with LABA/LAMA/ICS therapy. Within four weeks after initial diagnosis, ICS-containing therapies were prescribed in 14.1% of patients. Of all patients with a prescribed triple therapy, 68.9% had no corresponding exacerbation history documented. On average, 0.16 severe exacerbations and 0.19 COPD-related hospitalizations were observed per PY during available follow-up. Direct COPD-related costs were 3,693 €/PY, with COPD-related hospitalizations being responsible for about 79.2% of these costs. Conclusion Long-acting bronchodilators are the mainstay of pharmacological treatment of incident COPD patients in Germany, in line with guideline recommendations. Yet, a considerable proportion of incident COPD patients did not receive any inhaled maintenance therapy.
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Affiliation(s)
- Roland Buhl
- Pulmonary Department, Mainz University Hospital, Mainz, Germany
| | | | - Nils Picker
- Cytel Inc - Ingress-Health HWM GmbH, Wismar, Germany
| | | | | | - Anke Kondla
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | | | - Claus F Vogelmeier
- Department of Medicine, Pulmonary and Critical Care Medicine, Philipps University of Marburg (UMR), Member of the German Center for Lung Research (DZL), Marburg, Germany
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Bamonti PM, Robinson SA, Wan ES, Moy ML. Improving Physiological, Physical, and Psychological Health Outcomes: A Narrative Review in US Veterans with COPD. Int J Chron Obstruct Pulmon Dis 2022; 17:1269-1283. [PMID: 35677347 PMCID: PMC9167842 DOI: 10.2147/copd.s339323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 05/19/2022] [Indexed: 11/23/2022] Open
Abstract
The Veterans Health Administration (VHA) is the largest integrated healthcare system in the United States (US) providing healthcare to an increasing number of middle-aged and older adults who remain at greater risk for chronic obstructive pulmonary disease (COPD) compared to their civilian counterparts. The VHA has obligated research funds, drafted clinical guidelines, and built programmatic infrastructure to support the diagnosis, treatment, and care management of Veterans with COPD. Despite these efforts, COPD remains a leading cause of morbidity and mortality in Veterans. This paper provides a narrative review of research conducted with US Veteran samples targeting improvement in COPD outcomes. We review key physiological, physical, and psychological health outcomes and intervention research that included US Veteran samples. We conclude with a discussion of directions for future research to continue advancing the treatment of COPD in Veterans and inform advancements in COPD research within and outside the VHA.
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Affiliation(s)
- Patricia M Bamonti
- Research & Development, VA Boston Healthcare System, Boston, MA, USA.,Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Stephanie A Robinson
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA.,The Pulmonary Center, Boston University School of Medicine, Boston, MA, USA
| | - Emily S Wan
- Research & Development, VA Boston Healthcare System, Boston, MA, USA.,Pulmonary and Critical Care Medicine Section, VA Boston Healthcare System, Boston, MA, USA.,Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Marilyn L Moy
- Research & Development, VA Boston Healthcare System, Boston, MA, USA.,Pulmonary and Critical Care Medicine Section, VA Boston Healthcare System, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
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Bamonti PM, Boyle JT, Goodwin CL, Wan ES, Silberbogen AK, Finer EB, Moy ML. Predictors of Outpatient Pulmonary Rehabilitation Uptake, Adherence, Completion, and Treatment Response Among Male U.S. Veterans With Chronic Obstructive Pulmonary Disease. Arch Phys Med Rehabil 2021; 103:1113-1121.e1. [PMID: 34856155 DOI: 10.1016/j.apmr.2021.10.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 09/03/2021] [Accepted: 10/11/2021] [Indexed: 11/02/2022]
Abstract
OBJECTIVE To examine predictors of uptake (never start), adherence (drop out), and completion of pulmonary rehabilitation (PR), as well as PR treatment response based on minimal clinically important difference (MCID) on the 6-minute walk test (6MWT) distance and Chronic Respiratory Questionnaire-Self-Report (CRQ-SR). DESIGN Retrospective, cohort study. SETTING Veterans Health Administration. PARTICIPANTS U.S. veterans with chronic obstructive pulmonary disease (COPD) (N=253) referred to PR between 2010 and 2018. INTERVENTIONS Outpatient PR program. MAIN OUTCOME MEASURES Participants completed baseline (time 1) measures of depression (Beck Depression Inventory-II), health-related quality of life (CRQ-SR), self-efficacy (Exercise Self-Regulatory Efficacy Scale [Ex-SRES]), and COPD knowledge. Exercise capacity was assessed with the 6MWT. Participants who completed all 18 sessions of PR repeated assessments (time 2). Logistic regression models examined predictors of uptake, adherence, and completion of PR as well as treatment response based on MCID. RESULTS Participants were referred to PR with 24.90% never starting, 28.90% dropping out, and 46.20% completing. No differences emerged between never starters and dropouts. Having a history of any cancer increased the likelihood of completing PR (vs never starting; odds ratio [OR], 3.18; P=.003). Greater CRQ-SR dyspnea score, indicating less dyspnea, was associated with increased likelihood of completing PR (OR, 1.12; P=.006). Past smoking compared with current smoking was associated with increased likelihood of completion (OR, 3.89; P≤.002). Those without a history of alcohol use disorder had increased likelihood of completing PR (OR, 2.23; P=.048). Greater baseline 6MWT distance was associated with lower likelihood of achieving MCID in 6MWT (OR, 0.99; P<.001). Greater Ex-SRES was associated with decreased likelihood of achieving 6MWT MCID (OR, 0.98; P=.023). CONCLUSIONS Findings suggest that early psychoeducation on dyspnea management and smoking and alcohol cessation may increase completion of PR.
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Affiliation(s)
- Patricia M Bamonti
- VA New England Geriatric Research Education and Clinical Center (GRECC), VA Boston Healthcare System, Boston, MA; Department of Psychiatry, Harvard Medical School, Boston, MA.
| | | | | | - Emily S Wan
- Pulmonary and Critical Care Medicine Section, VA Boston Healthcare System, Boston, MA; Department of Medicine, Harvard Medical School, Boston, MA; Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, MA
| | - Amy K Silberbogen
- VA Boston Healthcare System, Boston, MA; Boston University School of Medicine, Boston, MA
| | - Elizabeth B Finer
- Pulmonary and Critical Care Medicine Section, VA Boston Healthcare System, Boston, MA
| | - Marilyn L Moy
- Pulmonary and Critical Care Medicine Section, VA Boston Healthcare System, Boston, MA; Department of Medicine, Harvard Medical School, Boston, MA
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Fortis S, Gao Y, O'Shea AMJ, Beck B, Kaboli P, Vaughan Sarrazin M. Hospital Variation in Non-Invasive Ventilation Use for Acute Respiratory Failure Due to COPD Exacerbation. Int J Chron Obstruct Pulmon Dis 2021; 16:3157-3166. [PMID: 34824529 PMCID: PMC8609200 DOI: 10.2147/copd.s321053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 09/13/2021] [Indexed: 02/03/2023] Open
Abstract
Background Non-invasive mechanical ventilation (NIV) use in patients admitted with acute respiratory failure due to COPD exacerbations (AECOPDs) varies significantly between hospitals. However, previous literature did not account for patients’ illness severity. Our objective was to examine the variation in risk-standardized NIV use after adjusting for illness severity. Methods We retrospectively analyzed AECOPD hospitalizations from 2011 to 2017 at 106 acute-care Veterans Health Administration (VA) hospitals in the USA. We stratified hospitals based on the percentage of NIV use among patients who received ventilation support within the first 24 hours of admission into quartiles, and compared patient characteristics. We calculated the risk-standardized NIV % using hierarchical models adjusting for comorbidities and severity of illness. We then stratified the hospitals by risk-standardized NIV % into quartiles and compared hospital characteristics between quartiles. We also compared the risk-standardized NIV % between rural and urban hospitals. Results In 42,048 admissions for AECOPD over 6 years, the median risk-standardized initial NIV % was 57.3% (interquartile interval [IQI]=41.9–64.4%). Hospitals in the highest risk-standardized NIV % quartiles cared for more rural patients, used invasive ventilators less frequently, and had longer length of hospital stay, but had no difference in mortality relative to the hospitals in the lowest quartiles. The risk-standardized NIV % was 65.3% (IQI=34.2–84.2%) in rural and 55.1% (IQI=10.8–86.6%) in urban hospitals (p=0.047), but hospital mortality did not differ between the two groups. Conclusion NIV use varied significantly across hospitals, with rural hospitals having higher risk-standardized NIV % rates than urban hospitals. Further research should investigate the exact mechanism of variation in NIV use between rural and urban hospitals.
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Affiliation(s)
- Spyridon Fortis
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA.,Department of Internal Medicine, Division of Pulmonary, Critical Care and Occupation Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Yubo Gao
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA.,Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Amy M J O'Shea
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA.,Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Brice Beck
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA
| | - Peter Kaboli
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA.,Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Mary Vaughan Sarrazin
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA.,Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
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Fortis S, Wan ES, Kunisaki K, Eyck PT, Ballas ZK, Bowler RP, Crapo JD, Hokanson JE, Wendt C, Silverman EK, Comellas AP. Increased mortality associated with frequent exacerbations in COPD patients with mild-to-moderate lung function impairment, and smokers with normal spirometry. RESPIRATORY MEDICINE: X 2021; 3. [PMID: 35911870 PMCID: PMC9333066 DOI: 10.1016/j.yrmex.2020.100025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Methods: Results: Conclusions:
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Affiliation(s)
- Spyridon Fortis
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA
- Division of Pulmonary, Critical Care and Occupational Medicine, University of Iowa Hospital and Clinics, Iowa City, IA, USA
- Corresponding author. UIHC – Internal Medicine, 200 Hawkins Drive – C33 GH, Iowa City, IA, 52242, USA. (S. Fortis)
| | - Emily S. Wan
- Channing Division of Network Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- VA Boston Healthcare System, Jamaica Plain, MA, USA
| | - Ken Kunisaki
- Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
- University of Minnesota, Minneapolis, MN, USA
| | - Patrick Tel Eyck
- Biostatistics and Research Design, Institute for Clinical and Translational Science, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Zuhair K. Ballas
- Division of Immunology, Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | | | - James D. Crapo
- Department of Medicine, National Jewish Health, Denver, CO, USA
| | - John E. Hokanson
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Chris Wendt
- Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
- University of Minnesota, Minneapolis, MN, USA
| | - Edwin K. Silverman
- Channing Division of Network Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Alejandro P. Comellas
- Division of Pulmonary, Critical Care and Occupational Medicine, University of Iowa Hospital and Clinics, Iowa City, IA, USA
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Rana R, Gow J, Moloney C, King A, Keijzers G, Beccaria G, Mullens A. Estimating the frequency and cost of emergency department presentations and hospitalisation of chronic obstructive pulmonary disease patients: A retrospective analysis from regional Queensland. Emerg Med Australas 2021; 33:491-498. [PMID: 33128441 DOI: 10.1111/1742-6723.13665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 09/19/2020] [Accepted: 10/01/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Chronic obstructive pulmonary disease (COPD) patients commonly have frequent visits to the ED. Consequently, COPD has a significant effect on total healthcare expenditure. The objective was to measure the frequency of ED presentation and hospitalisation among COPD patients and to estimate the costs resulting from such care utilisation. METHODS This was a causal-comparative non-experimental research design conducted in three regional hospitals between 2016 and 2018. Two different original data sets were used: an automated hospital data set and an audit of patient charts. Secondary cost data were also used. Data were analysed using Pearson's χ2 test to estimate the relationship between several patient and treatment-related characteristics. RESULTS There were 5253 patient presentations at ED and hospital length of stay data were available for 5079 COPD patients. The total cost of hospital stays was $42.14 million for the time period and the mean average cost was $8297 for ED patients who were admitted to hospital. Factors significantly associated with hospital length of stay were age and time spent in the ED. Noticeably, one (51.7%) in two COPD patients were discharged from ED (all destinations) within 4 h irrespective of their triage category. CONCLUSIONS COPD patient presentation to ED and admission to hospital is an expensive method of providing healthcare to manage this chronic condition. Clinical practitioners and policy makers need to develop and implement optimal integrated care management systems to reduce this hospitalisation rate and reduce the societal costs associated with COPD patient management.
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Affiliation(s)
- Rezwanul Rana
- School of Commerce, University of Southern Queensland, Toowoomba, Queensland, Australia
| | - Jeff Gow
- School of Commerce, University of Southern Queensland, Toowoomba, Queensland, Australia
- School of Accounting, Economics and Finance, University of KwaZulu-Natal, Durban, South Africa
| | - Clint Moloney
- School of Nursing and Midwifery, University of Southern Queensland, Toowoomba, Queensland, Australia
| | - Alex King
- Emergency Department, Toowoomba Hospital, Darling Downs Hospital and Health Service, Toowoomba, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Gerben Keijzers
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Gavin Beccaria
- School of Psychology, University of Southern Queensland, Toowoomba, Queensland, Australia
| | - Amy Mullens
- School of Psychology, University of Southern Queensland, Toowoomba, Queensland, Australia
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Duan KI, Spece LJ, Wong ES, Feemster LC, Donovan LM, Griffith MF, Keller TL, Bryant AD, Au DH. Low-Value Inhaled Corticosteroids in Chronic Obstructive Pulmonary Disease and the Association with Healthcare Utilization and Costs. Ann Am Thorac Soc 2021; 18:989-996. [PMID: 33290180 PMCID: PMC8456735 DOI: 10.1513/annalsats.202009-1128oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 12/08/2020] [Indexed: 11/20/2022] Open
Abstract
Rationale: Inhaled corticosteroids (ICS) are not first-line therapy for patients with chronic obstructive pulmonary disease (COPD) at low risk of exacerbations, but they are commonly prescribed despite evidence of harm. We consider ICS prescription in this population to be of "low value." The association of low-value ICS with subsequent healthcare utilization and costs is unknown. Understanding this relationship could inform efforts to reduce the delivery of low-value care. Objectives: To determine whether low-value ICS prescribing is associated with higher outpatient healthcare utilization and costs among patients with COPD who are at low risk of exacerbation. Methods: We performed a cohort study between January 1, 2010, and December 31, 2018, identifying a cohort of veterans with COPD who performed pulmonary function tests (PFTs) at 21 Veterans Affairs medical centers nationwide. Patients were defined as having low exacerbation risk if they experienced less than two outpatient exacerbations and no hospital admissions for COPD in the year before PFTs. Our primary exposure was the receipt of an ICS prescription in the 3 months before the date of PFTs. Our primary outcomes were outpatient utilization and outpatient costs in the 1 year after PFTs. For inference, we generated negative binomial models for utilization and generalized linear models for costs, adjusting for confounders. Results: We identified a total of 31,551 patients with COPD who were at low risk of exacerbation. Of these patients, 9,742 were prescribed low-value ICS (mean [standard deviation (SD)] age, 69 [9] yr), and 21,809 were not prescribed low-value ICS (mean [SD] age, 68 [9] yr). Compared with unexposed patients, those exposed to low-value ICS had 0.53 more encounters per patient per year (95% confidence interval CI, 0.23-0.83) and incurred $154.72 higher costs/patient/year (95% CI, $45.58-$263.86). Conclusions: Low-value ICS prescription was associated with higher subsequent outpatient healthcare utilization and costs. Potential mechanisms for the observed association are that 1) low-value ICS may be a marker of poor respiratory symptom control, 2) there is confounding by indication, or 3) low-value ICS results in increased drug costs or utilization. Health systems should identify low-value ICS prescriptions as a target to improve value-based care.
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Affiliation(s)
- Kevin I. Duan
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
| | - Laura J. Spece
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
| | - Edwin S. Wong
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Department of Health Services, University of Washington, Seattle, Washington
| | - Laura C. Feemster
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
| | - Lucas M. Donovan
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
| | - Matthew F. Griffith
- Health Services Research and Development, Veterans Affairs Eastern Colorado Health Care System, Aurora, Colorado; and
- Division of Pulmonary Sciences and Critical Care, University of Colorado, Aurora, Colorado
| | - Thomas L. Keller
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
| | - Alexander D. Bryant
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
| | - David H. Au
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
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Fortis S, O'Shea AMJ, Beck BF, Comellas A, Vaughan Sarrazin M, Kaboli PJ. Association Between Rural Residence and In-Hospital and 30-Day Mortality Among Veterans Hospitalized with COPD Exacerbations. Int J Chron Obstruct Pulmon Dis 2021; 16:191-202. [PMID: 33564232 PMCID: PMC7866931 DOI: 10.2147/copd.s281162] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 12/11/2020] [Indexed: 12/30/2022] Open
Abstract
Background We explored the relationship between rural residency and in-hospital mortality in patients hospitalized with COPD exacerbations. Methods We retrospectively analyzed COPD hospitalizations from 2011 to 2017 at 124 acute care Veterans Health Administration (VHA) hospitals in the US. Patient residence was classified using Rural Urban Commuting Area codes as urban, rural, or isolated rural. We stratified patient hospitalizations into quartiles by travel time from patient residence to the nearest VHA primary care provider clinic and hospital. Multivariate analyses utilized generalized estimating equations with a logit link accounting for repeated hospitalizations among patients and adjusting for patient- and hospital-level characteristics. Results Of 64,914 COPD hospitalizations analyzed, 43,549 (67.1%) were for urban, 18,673 (28.8%) for rural, and 2,692 (4.1%) for isolated rural veterans. In-hospital mortality was 4.9% in urban, 5.5% in rural, and 5.2% in isolated rural veterans (P=0.008). Thirty-day mortality was 8.3% in urban, 9.9% in rural, and 9.2% in isolated rural veterans (P<0.001). Travel time to a primary care provider and VHA hospital was not associated with in-hospital mortality among isolated rural and rural veterans. In the multivariable analysis, compared to urban veterans, isolated rural patients did not have increased mortality. Rural residence was not associated with in-hospital (OR=0.87; 95% CI=0.67-1.12, P=0.28) but was associated with increased 30-day mortality (OR=1.13; 95% CI=1.04-1.22, P=0.002). Transfer from another acute care hospital (OR=14.97; 95% CI=9.80-17.16, P<0.001) or an unknown/other facility (OR=33.05; 95% CI=22.66-48.21, P<0.001) were the strongest predictors of increased in-hospital mortality compared to patients coming from the outpatient sector. Transfer from another acute care facility was also a risk factor for 30-day mortality. Conclusion Potential gaps in post-discharge care of rural veterans may be responsible for the rural-urban disparities. Further research should investigate the exact mechanism that inter-hospital transfers affect mortality.
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Affiliation(s)
- Spyridon Fortis
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA.,Pulmonary, Critical Care and Occupational Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Amy M J O'Shea
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA.,Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Brice F Beck
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA
| | - Alejandro Comellas
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA.,Pulmonary, Critical Care and Occupational Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Mary Vaughan Sarrazin
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA.,Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Peter J Kaboli
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA.,Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
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Effect of BMI on health care expenditures stratified by COPD GOLD severity grades: Results from the LQ-DMP study. Respir Med 2020; 175:106194. [PMID: 33166903 DOI: 10.1016/j.rmed.2020.106194] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 10/13/2020] [Accepted: 10/14/2020] [Indexed: 12/11/2022]
Abstract
Chronic Obstructive Pulmonary Disease (COPD) is characterized by persistent respiratory symptoms and airflow limitation, which is progressive and not fully reversible. In patients with COPD, body mass index (BMI) is an important parameter associated with health outcomes, e.g. mortality and health-related quality of life. However, so far no study evaluated the association of BMI and health care expenditures across different COPD severity grades. We used claims data and documentation data of a Disease Management Program (DMP) from a statutory health insurance fund (AOK Bayern). Patients were excluded if they had less than 4 observations in the 8 years observational period. Generalized additive mixed models with smooth functions were used to evaluate the association between BMI and health care expenditures, stratified by severity of COPD, indicated by GOLD grades 1-4. We included 30,682 patients with overall 188,725 observations. In GOLD grades 1-3 we found an u-shaped relation of BMI and expenditures, where patients with a BMI of 30 or slightly above had the lowest and underweight and obese patients had the highest health care expenditures. Contrarily, in GOLD grade 4 we found an almost linear decline of health care expenditures with increasing BMI. In terms of expenditures, the often reported obesity paradox in patients with COPD was clearly reflected in GOLD grade 4, while in all other severity grades underweight as well as severely obese patients caused the highest health care expenditures. Reduction of obesity may thus reduce health care expenditures in GOLD grades 1-3.
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16
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Smooth Bayesian network model for the prediction of future high-cost patients with COPD. Int J Med Inform 2019; 126:147-155. [PMID: 31029256 DOI: 10.1016/j.ijmedinf.2019.03.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 02/28/2019] [Accepted: 03/26/2019] [Indexed: 02/05/2023]
Abstract
INTRODUCTION The clinical course of chronic obstructive pulmonary disease (COPD) is marked by acute exacerbation events that increase hospitalization rates and healthcare spending. The early identification of future high-cost patients with COPD may decrease healthcare spending by informing individualized interventions that prevent exacerbation events and decelerate disease progression. Existing studies of cost prediction of other chronic diseases have applied regression and machine-learning methods that cannot capture the complex causal relationships between COPD factors. Thus, the exploration of these factors through nonlinear, high-dimensional but explainable modeling is greatly needed. OBJECTIVES We aimed to develop a machine-learning model to identify future high-cost patients with COPD. Such a model should incorporate expert knowledge about causal relationships, and the method for estimating the model could provide more accurate predictions than other machine learning methods. METHODS We used the 2011-2013 medical insurance data of patients with COPD in a large city. The data set included demographic information and admission records. Leveraging on developments in graphical modeling methods, we proposed a smooth Bayesian network (SBN) model for the prediction of high-cost individuals using medical insurance data. The modeling method incorporated some expert knowledge about causal relationships (i.e., about the Bayesian network structure). We employed a smoothing kernel based on the weighted nearest neighborhood method in the SBN model to address overfitting, case-mix effect, and data sparsity (i.e., using data about "similar patients"). RESULTS The proposed SBN achieved the area under curve (AUC) of 0.80 and showed considerable improvement over the baseline machine-learning methods. Besides confirming the known factors from the literature, we found "region" (i.e., a suburban or urban area) to be a significant factor, and that in a 3-tier system with primary, secondary and tertiary hospitals, COPD patients who had been admitted to primary hospitals were more likely to develop into future high-cost patients than patients who had been admitted to tertiary hospitals. CONCLUSION The proposed SBN model not only obtained higher prediction accuracy and stronger generalizability than a number of benchmark machine-learning methods, but also used the Bayesian network to capture the complex causal relationships between different predictors by incorporating expert knowledge. Furthermore, a framework was developed to establish the relationships between exposure to historical trajectory and future outcome, which can also be applied to other temporal data to model different trajectory information and predict other outcomes.
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Rinne ST, Wiener RS, Chen Y, Rise P, Udris E, Feemster LC, Au DH. Impact of Guideline Changes on Indications for Inhaled Corticosteroids among Veterans with Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2018; 198:1226-1228. [PMID: 29969041 PMCID: PMC6221578 DOI: 10.1164/rccm.201803-0554le] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Seppo T. Rinne
- U.S. Department of Veterans AffairsBedford, Massachusetts
- Boston University School of MedicineBoston, Massachusetts
| | - Renda Soylemez Wiener
- U.S. Department of Veterans AffairsBedford, Massachusetts
- Boston University School of MedicineBoston, Massachusetts
| | - Yahong Chen
- Peking University Third HospitalBeijing, China
| | - Peter Rise
- VA Puget Sound Health Care SystemSeattle, Washingtonand
| | - Edmunds Udris
- VA Puget Sound Health Care SystemSeattle, Washingtonand
| | - Laura C. Feemster
- VA Puget Sound Health Care SystemSeattle, Washingtonand
- University of WashingtonSeattle, Washington
| | - David H. Au
- VA Puget Sound Health Care SystemSeattle, Washingtonand
- University of WashingtonSeattle, Washington
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18
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Cypel YS, Hines SE, Davey VJ, Eber SM, Schneiderman AI. Self-reported physician-diagnosed chronic obstructive pulmonary disease and spirometry patterns in Vietnam Era US Army Chemical Corps veterans: A retrospective cohort study. Am J Ind Med 2018; 61:802-814. [PMID: 30159906 DOI: 10.1002/ajim.22900] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2018] [Indexed: 01/23/2023]
Abstract
BACKGROUND Research on chronic obstructive pulmonary disease (COPD) and herbicide exposure in Vietnam War veterans is limited. METHODS Survey data were collected from 3193 US Army Chemical Corps veterans on herbicide exposure and self-reported physician-diagnosed COPD. Three spirometric patterns were used to define airflow obstruction (AFO): (i) FEV1 /FVC < 70% ("fixed ratio"); (ii) FEV1 /FVC < lower limit of normal ("LLN"); and (iii) (FEV1 /FVC < LLN and FVC ≥ LLN and FEV1 <LLN) or (FEV1 /FVC<LLN and FEV1 ≥ LLN) ("specific obstruction"). Associations between herbicide exposure and self-reported COPD and spirometric-AFO were determined using regression. RESULTS COPD prevalence varied (self-reports: 20.1%; spirometry: 29.8%, 12.9%, 8.4% by fixed ratio, LLN, and specific obstruction definitions, respectively). Spirometric parameters did not differ by exposure. Self-reported COPD and herbicide exposure were significantly associated (adjusted odds ratio [aOR] = 1.82, 95% confidence intervaI: 1.48,2.24). No association was found between spirometric-AFO and herbicide exposure. CONCLUSIONS A significant association was found between herbicide exposure and self-reported physician-diagnosed COPD but not when COPD diagnosis was based on spirometry.
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Affiliation(s)
- Yasmin S. Cypel
- Epidemiology Program; Post Deployment Health Services (10P4Q); Office of Patient Care Services; Department of Veterans Affairs; Washington District of Columbia
| | - Stella E. Hines
- Division of Occupational and Environmental Medicine and Division of Pulmonary and Critical Care Medicine, Department of Medicine, School of Medicine, University of Maryland-Baltimore; Baltimore Veterans Affairs Medical Center; Baltimore Maryland
| | - Victoria J. Davey
- Office of Research and Development, Veterans Health Administration; Department of Veterans Affairs; Washington District of Columbia
| | - Stephanie M. Eber
- Epidemiology Program; Post Deployment Health Services (10P4Q); Office of Patient Care Services; Department of Veterans Affairs; Washington District of Columbia
| | - Aaron I. Schneiderman
- Epidemiology Program; Post Deployment Health Services (10P4Q); Office of Patient Care Services; Department of Veterans Affairs; Washington District of Columbia
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Kwak MJ, Kim J, Bhise V, Chung TH, Petitto GS. National Trends in Smoking Cessation Medication Prescriptions for Smokers With Chronic Obstructive Pulmonary Disease in the United States, 2007-2012. J Prev Med Public Health 2018; 51:257-262. [PMID: 30286598 PMCID: PMC6182275 DOI: 10.3961/jpmph.18.119] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 08/23/2018] [Indexed: 12/02/2022] Open
Abstract
Objectives Smoking cessation decreases morbidity and mortality due to chronic obstructive pulmonary disease (COPD). Pharmacotherapy for smoking cessation is highly effective. However, the optimal prescription rate of smoking cessation medications among smokers with COPD has not been systemically studied. The purpose of this study was to estimate the national prescription rates of smoking cessation medications among smokers with COPD and to examine any disparities therein. Methods We conducted a retrospective study using National Ambulatory Medical Care Survey data from 2007 to 2012. We estimated the national prescription rate for any smoking cessation medication (varenicline, bupropion, and nicotine replacement therapy) each year. Multiple survey logistic regression was performed to characterize the effects of demographic variables and comorbidities on prescriptions. Results The average prescription rate of any smoking cessation medication over 5 years was 3.64%. The prescription rate declined each year, except for a slight increase in 2012: 9.91% in 2007, 4.47% in 2008, 2.42% in 2009, 1.88% in 2010, 1.46% in 2011, and 3.67% in 2012. Hispanic race and depression were associated with higher prescription rates (odds ratio [OR], 5.15; 95% confidence interval [CI], 1.59 to 16.67 and OR, 2.64; 95% CI, 1.26 to 5.51, respectively). There were no significant differences according to insurance, location of the physician, or other comorbidities. The high OR among Hispanic population and those with depression was driven by the high prescription rate of bupropion. Conclusions The prescription rate of smoking cessation medications among smokers with COPD remained low throughout the study period. Further studies are necessary to identify barriers and to develop strategies to overcome them.
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Affiliation(s)
- Min Ji Kwak
- Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA.,Department of Management Policy and Community Health, University of Texas School of Public Health, Houston, TX, USA
| | - Jongoh Kim
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Viraj Bhise
- Department of Management Policy and Community Health, University of Texas School of Public Health, Houston, TX, USA.,Department of Internal Medicine, John A Burns School of Medicine, University of Hawaii at Manoa, Honolulu, HI, USA
| | - Tong Han Chung
- Healthcare Transformation Initiatives, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Gabriela Sanchez Petitto
- Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
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Metabolomics in COPD Acute Respiratory Failure Requiring Noninvasive Positive Pressure Ventilation. Can Respir J 2017; 2017:9480346. [PMID: 29391845 PMCID: PMC5748128 DOI: 10.1155/2017/9480346] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 09/24/2017] [Accepted: 10/16/2017] [Indexed: 11/18/2022] Open
Abstract
We aimed to investigate whether metabolomic analysis can discriminate acute respiratory failure due to COPD exacerbation from respiratory failure due to heart failure and pneumonia. Since COPD exacerbation is often overdiagnosed, we focused on those COPD exacerbations that were severe enough to require noninvasive mechanical ventilation. We enrolled stable COPD subjects and patients with acute respiratory failure requiring noninvasive mechanical ventilation due to COPD, heart failure, and pneumonia. We excluded subjects with history of both COPD and heart failure and patients with obstructive sleep apnea and obstructive lung disease other than COPD. We performed metabolomics analysis using NMR. We constructed partial least squares discriminant analysis (PLS-DA) models to distinguish metabolic profiles. Serum (p=0.001, R2 = 0.397, Q2 = 0.058) and urine metabolic profiles (p < 0.001, R2 = 0.419, Q2 = 0.142) were significantly different between the four diagnosis groups by PLS-DA. After excluding stable COPD patients, the metabolomes of the various respiratory failure groups did not cluster separately in serum (p=0.2, R2 = 0.631, Q2 = 0.246) or urine (p=0.065, R2 = 0.602, Q2 = −0.134). However, several metabolites in the serum were reduced in patients with COPD exacerbation and pneumonia. We did not find a metabolic profile unique to COPD exacerbation, but we were able to clearly and reliably distinguish stable COPD patients from patients with respiratory failure in both serum and urine.
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Cornwell LD, Echeverria AE, Samuelian J, Mayor J, Casal RF, Bakaeen FG, Omer S, Preventza O, Mai W, Chen G, Simpson KH, Moghanaki D, Zhu AW. Video-assisted thoracoscopic lobectomy is associated with greater recurrence-free survival than stereotactic body radiotherapy for clinical stage I lung cancer. J Thorac Cardiovasc Surg 2017; 155:395-402. [PMID: 28888379 DOI: 10.1016/j.jtcvs.2017.07.065] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 07/05/2017] [Accepted: 07/17/2017] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Stereotactic body radiotherapy is the standard treatment for medically inoperable early-stage non-small cell lung cancer. Recent data suggest that in operable patients, stereotactic body radiotherapy produces outcomes comparable to those of surgical resection. In veterans with early non-small cell lung cancer, we compared the outcomes of stereotactic body radiotherapy and video-assisted thoracoscopic lobectomy. METHODS We retrospectively reviewed data from 183 patients (94.0% male) with clinical stage I non-small cell lung cancer who underwent stereotactic body radiotherapy (n = 56) or video-assisted thoracoscopic lobectomy (n = 127) from 2009 to 2014. Propensity matching was used to produce more comparable groups. Primary end points were tumor control and overall, recurrence-free, and lung-cancer-specific survival, as estimated by Kaplan-Meier actuarial analysis. Multivariable analysis was used to identify independent predictors. RESULTS In the overall cohort, the patients who received stereotactic body radiotherapy were older than the patients who received video-assisted thoracoscopic lobectomy (median age, 79.5 vs 64 years) and had more comorbidities. In the 37 propensity-matched pairs, the 3-year actuarial tumor control rate was 54.3% after stereotactic body radiotherapy and 90.6% after video-assisted thoracoscopic lobectomy (P = .0038). Actuarial lung cancer-specific 3-year survival was 78.1% (stereotactic body radiotherapy) versus 93.6% (video-assisted thoracoscopic lobectomy) (P = .055). One-year overall, 3-year overall, and 3-year recurrence-free survivals were 89.2%, 52.9%, and 38.5% after stereotactic body radiotherapy and 94.6%, 85.7%, and 82.8% after video-assisted thoracoscopic lobectomy (P < .005 for all), respectively. In multivariable analysis, stereotactic body radiotherapy independently predicted recurrence and poorer survival. CONCLUSIONS In veteran patients with early-stage non-small cell lung cancer, video-assisted thoracoscopic lobectomy resulted in better disease control and survival than stereotactic body radiotherapy. Although prior reports suggest that stereotactic body radiotherapy is a suitable alternative to surgery in early-stage lung cancer, a prospective randomized trial is needed. Nevertheless, stereotactic body radiotherapy remains a suitable option for medically inoperable patients.
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Affiliation(s)
- Lorraine D Cornwell
- Michael E. DeBakey VA Medical Center, Houston, Tex; Baylor College of Medicine, Houston, Tex.
| | - Alfredo E Echeverria
- Michael E. DeBakey VA Medical Center, Houston, Tex; Baylor College of Medicine, Houston, Tex
| | | | - Jessica Mayor
- Michael E. DeBakey VA Medical Center, Houston, Tex; Baylor College of Medicine, Houston, Tex
| | - Roberto F Casal
- Michael E. DeBakey VA Medical Center, Houston, Tex; Baylor College of Medicine, Houston, Tex
| | - Faisal G Bakaeen
- Cleveland Clinic, Cleveland, Ohio; Texas Heart Institute, Houston, Tex
| | - Shuab Omer
- Michael E. DeBakey VA Medical Center, Houston, Tex; Baylor College of Medicine, Houston, Tex
| | - Ourania Preventza
- Baylor College of Medicine, Houston, Tex; Texas Heart Institute, Houston, Tex
| | - Weiyuan Mai
- Michael E. DeBakey VA Medical Center, Houston, Tex; Baylor College of Medicine, Houston, Tex
| | - George Chen
- Michael E. DeBakey VA Medical Center, Houston, Tex; Baylor College of Medicine, Houston, Tex
| | | | - Drew Moghanaki
- The Hunter Holmes McGuire VA Medical Center, Richmond, Va
| | - Angela W Zhu
- Michael E. DeBakey VA Medical Center, Houston, Tex; Baylor College of Medicine, Houston, Tex
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Cho J, Copeland LA, Stock EM, Zeber JE, Restrepo MI, MacCarthy AA, Ory MG, Smith PA, Stevens AB. Protective and Risk Factors for 5-Year Survival in the Oldest Veterans: Data from the Veterans Health Administration. J Am Geriatr Soc 2017; 64:1250-7. [PMID: 27321603 DOI: 10.1111/jgs.14161] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES To characterize physical and mental diseases and use of healthcare services and identify factors associated with mortality in the oldest individuals using the Veterans Health Administration (VHA). DESIGN Retrospective study with 5-year survival follow-up. SETTING VHA, system-wide. PARTICIPANTS Veterans using the VHA aged 80 and older as of October 2008 (N = 721,588: n = 665,249 aged 80-89, n = 56,118 aged 90-99, n = 221 aged 100-115). MEASUREMENTS Demographic characteristics, physical and mental diseases, healthcare services, and 5-year survival were measured. RESULTS Accelerated failure time models identified protective and risk factors associated with mortality according to age group. During 5 years of follow-up, 44% of participants died (survival rate: 59% aged 80-89, 32% aged 90-99, 15% aged ≥100). In the multivariable model, protective effects for veterans aged 80-99 were female sex, minority race or ethnicity, being married, having certain physical and mental diagnoses (hypertension, cataract, dyslipidemia, posttraumatic stress disorder, bipolar disorder), having urgent care visits, having invasive surgery, and having few (1-3) prescriptions. Risk factors were lower VHA priority status, physical and mental conditions (diabetes mellitus, anemia, congestive heart failure, dementia, anxiety, depression, smoking, substance abuse disorder), hospital admission, and nursing home care. For those aged 100 and older, being married, smoking, hospital admission, nursing home care, invasive surgery, and prescription use were significant risk factors; only emergency department (ED) use was protective. CONCLUSION Although the data are limited to VHA care (thus missing Medicare services), this study shows that many veterans served by the VHA live to advanced old age despite multiple chronic conditions. Further study is needed to determine whether a comprehensive, coordinated care system like VHA is associated with greater longevity for very old persons.
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Affiliation(s)
- Jinmyoung Cho
- Baylor Scott & White Health, Temple, Texas.,Texas A&M Health Science Center, College Station, Texas
| | - Laurel A Copeland
- Baylor Scott & White Health, Temple, Texas.,Texas A&M Health Science Center, College Station, Texas.,Central Texas Veterans Health Care System, Temple, Texas
| | - Eileen M Stock
- Baylor Scott & White Health, Temple, Texas.,Texas A&M Health Science Center, College Station, Texas.,Central Texas Veterans Health Care System, Temple, Texas
| | - John E Zeber
- Baylor Scott & White Health, Temple, Texas.,Texas A&M Health Science Center, College Station, Texas.,Central Texas Veterans Health Care System, Temple, Texas
| | - Marcos I Restrepo
- University of Texas Health Science Center San Antonio, San Antonio, Texas.,South Texas Veterans Health Care System, San Antonio, Texas
| | | | - Marcia G Ory
- Texas A&M Health Science Center, College Station, Texas
| | | | - Alan B Stevens
- Baylor Scott & White Health, Temple, Texas.,Texas A&M Health Science Center, College Station, Texas
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Hoogendoorn M, Feenstra TL, Asukai Y, Briggs AH, Borg S, Dal Negro RW, Hansen RN, Jansson SA, Leidl R, Risebrough N, Samyshkin Y, Wacker ME, Rutten-van Mölken MPMH. Patient Heterogeneity in Health Economic Decision Models for Chronic Obstructive Pulmonary Disease: Are Current Models Suitable to Evaluate Personalized Medicine? VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2016; 19:800-810. [PMID: 27712708 DOI: 10.1016/j.jval.2016.04.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 02/18/2016] [Accepted: 04/03/2016] [Indexed: 05/26/2023]
Abstract
OBJECTIVES To assess how suitable current chronic obstructive pulmonary disease (COPD) cost-effectiveness models are to evaluate personalized treatment options for COPD by exploring the type of heterogeneity included in current models and by validating outcomes for subgroups of patients. METHODS A consortium of COPD modeling groups completed three tasks. First, they reported all patient characteristics included in the model and provided the level of detail in which the input parameters were specified. Second, groups simulated disease progression, mortality, quality-adjusted life-years (QALYs), and costs for hypothetical subgroups of patients that differed in terms of sex, age, smoking status, and lung function (forced expiratory volume in 1 second [FEV1] % predicted). Finally, model outcomes for exacerbations and mortality for subgroups of patients were validated against published subgroup results of two large COPD trials. RESULTS Nine COPD modeling groups participated. Most models included sex (seven), age (nine), smoking status (six), and FEV1% predicted (nine), mainly to specify disease progression and mortality. Trial results showed higher exacerbation rates for women (found in one model), higher mortality rates for men (two models), lower mortality for younger patients (four models), and higher exacerbation and mortality rates in patients with severe COPD (four models). CONCLUSIONS Most currently available COPD cost-effectiveness models are able to evaluate the cost-effectiveness of personalized treatment on the basis of sex, age, smoking, and FEV1% predicted. Treatment in COPD is, however, more likely to be personalized on the basis of clinical parameters. Two models include several clinical patient characteristics and are therefore most suitable to evaluate personalized treatment, although some important clinical parameters are still missing.
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Affiliation(s)
- Martine Hoogendoorn
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands.
| | - Talitha L Feenstra
- Department for Prevention and Health Services Research, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands; Department of Epidemiology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Yumi Asukai
- IMS Health, Health Economics and Outcomes Research and Real-World Evidence Solutions, London, UK
| | - Andrew H Briggs
- Institute of Health & Wellbeing, University of Glasgow, Glasgow, UK
| | - Sixten Borg
- The Swedish Institute for Health Economics, Lund, Sweden; Health Economics Unit, Department of Clinical Sciences in Malmö, Lund University, Lund, Sweden; Evidera, London, UK
| | - Roberto W Dal Negro
- National Center for Respiratory Pharmacoeconomics and Pharmacoepidemiology (CESFAR), Verona, Italy
| | - Ryan N Hansen
- Pharmaceutical Outcomes Research and Policy Program, School of Pharmacy, University of Washington, Seattle, WA, USA
| | - Sven-Arne Jansson
- Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine, The OLIN Unit, Umeå University, Umeå, Sweden
| | - Reiner Leidl
- Helmholtz Zentrum München, Institute of Health Economics and Health Care Management, Member of the German Center for Lung Research, Comprehensive Pneumology Center Munich, Neuherberg, Germany
| | | | - Yevgeniy Samyshkin
- IMS Health, Health Economics and Outcomes Research and Real-World Evidence Solutions, London, UK
| | - Margarethe E Wacker
- Helmholtz Zentrum München, Institute of Health Economics and Health Care Management, Member of the German Center for Lung Research, Comprehensive Pneumology Center Munich, Neuherberg, Germany
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Hillas G, Perlikos F, Tzanakis N. Acute exacerbation of COPD: is it the "stroke of the lungs"? Int J Chron Obstruct Pulmon Dis 2016; 11:1579-86. [PMID: 27471380 PMCID: PMC4948693 DOI: 10.2147/copd.s106160] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is one of the top five major causes of morbidity and mortality worldwide. Despite worldwide health care efforts, costs, and medical research, COPD figures demonstrate a continuously increasing tendency in mortality. This is contrary to other top causes of death, such as neoplasm, accidents, and cardiovascular disease. A major factor affecting COPD-related mortality is the acute exacerbation of COPD (AECOPD). Exacerbations and comorbidities contribute to the overall severity in individual patients. Despite the underestimation by the physicians and the patients themselves, AECOPD is a really devastating event during the course of the disease, similar to acute myocardial infarction in patients suffering from coronary heart disease. In this review, we focus on the evidence that supports the claim that AECOPD is the “stroke of the lungs”. AECOPD can be viewed as: a Semicolon or disease’s full-stop period, Triggering a catastrophic cascade, usually a Relapsing and Overwhelming event, acting as a Killer, needing Emergent treatment.
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Affiliation(s)
- Georgios Hillas
- Department of Critical Care and Pulmonary Services, University of Athens Medical School, Evangelismos Hospital, Athens
| | - Fotis Perlikos
- Department of Critical Care and Pulmonary Services, University of Athens Medical School, Evangelismos Hospital, Athens
| | - Nikolaos Tzanakis
- Department of Thoracic Medicine, University Hospital of Heraklion, Medical School, University of Crete, Crete, Greece
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Wan Y, Sun SX, Corman S, Huang X, Gao X, Shorr AF. A longitudinal, retrospective cohort study on the impact of roflumilast on exacerbations and economic burden among chronic obstructive pulmonary disease patients in the real world. Int J Chron Obstruct Pulmon Dis 2015; 10:2127-36. [PMID: 26504378 PMCID: PMC4603715 DOI: 10.2147/copd.s80106] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Roflumilast is approved in the United States to reduce the risk of COPD exacerbations in patients with severe COPD. Exacerbation rates, health care resource utilization (HCRU), and costs were compared between roflumilast patients and those receiving other COPD maintenance drugs. Methods LifeLink™ Health Plan Claims Database was used to identify patients diagnosed with COPD who initiated roflumilast (roflumilast group) or ≥3 other COPD maintenance drugs (non-roflumilast group) from May 1, 2011 to December 31, 2012. Patients must have been enrolled for 12 months before (baseline) and 3 months after (postindex) the initiation date, ≥40 years old, not systemic corticosteroid dependent, and without asthma diagnosis at baseline. Difference-in-difference models compared change from baseline in exacerbations, HCRU (office, emergency visits, and hospitalizations), and total costs between groups, adjusting for baseline differences. Results A total of 14,211 patients (roflumilast, n=710; non-roflumilast, n=13,501) were included. During follow-up, the rate of overall exacerbations per patient per month decreased by 11.1% in the roflumilast group and increased by 15.9% in the non-roflumilast group (P<0.001). After controlling for baseline differences, roflumilast-treated patients experienced a greater reduction in exacerbations (0.0160 fewer exacerbations per month, P=0.01), numerically greater reductions in hospital admissions (0.003 fewer per month, P=0.57), office visits (0.46 fewer per month, P=0.26), and total costs from baseline compared with non-roflumilast patients ($116 less per month, P=0.62). Conclusion In a real-world setting, patients initiating roflumilast experienced reductions in exacerbations versus patients treated with other COPD medications.
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Affiliation(s)
- Yin Wan
- Health Economics and Modeling, Outcomes Research, Pharmerit International, Bethesda, MD, USA
| | - Shawn X Sun
- Health Economics and Outcomes Research, Forest Laboratories, LLC, an affiliate of Actavis, Inc., Jersey City, NJ, USA
| | - Shelby Corman
- Health Economics and Modeling, Outcomes Research, Pharmerit International, Bethesda, MD, USA
| | - Xingyue Huang
- Health Economics and Outcomes Research, Forest Laboratories, LLC, an affiliate of Actavis, Inc., Jersey City, NJ, USA
| | - Xin Gao
- Health Economics and Modeling, Outcomes Research, Pharmerit International, Bethesda, MD, USA
| | - Andrew F Shorr
- Pulmonary Critical Care, Washington Hospital Center and Georgetown University, Washington, DC, USA
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26
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Tawara Y, Senjyu H, Tanaka K, Tanaka T, Asai M, Kozu R, Tabusadani M, Honda S, Sawai T. Value of systematic intervention for chronic obstructive pulmonary disease in a regional Japanese city based on case detection rate and medical cost. Int J Chron Obstruct Pulmon Dis 2015; 10:1531-42. [PMID: 26347397 PMCID: PMC4529261 DOI: 10.2147/copd.s82872] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVE We established a COPD taskforce for early detection, diagnosis, treatment, and intervention. We implemented a pilot intervention with a prospective and longitudinal design in a regional city. This study evaluates the usefulness of the COPD taskforce and intervention based on COPD case detection rate and per capita medical costs. METHOD We distributed a questionnaire to all 8,878 inhabitants aged 50-89 years, resident in Matsuura, Nagasaki Prefecture in 2006. Potentially COPD-positive persons received a pulmonary function test and diagnosis. We implemented ongoing detection, examination, education, and treatment interventions, performed follow-up examinations or respiratory lessons yearly, and supported the health maintenance of each patient. We compared COPD medical costs in Matsuura and in the rest of Nagasaki Prefecture using data from 2004 to 2013 recorded by the association of Nagasaki National Health Insurance Organization, assessing 10-year means and annual change. RESULTS As of 2014, 256 people have received a definitive diagnosis of COPD; representing 31% of the estimated total number of COPD patients. Of the cases detected, 87.5% were mild or moderate in severity. COPD medical costs per patient in Matsuura were significantly lower than the rest of Nagasaki Prefecture, as was rate of increase in cost over time. CONCLUSION The COPD program in Matsuura enabled early detection and treatment of COPD patients and helped to lower the associated burden of medical costs. The success of this program suggests that a similar program could reduce the economic and human costs of COPD morbidity throughout Japan.
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Affiliation(s)
- Yuichi Tawara
- Department of Cardiopulmonary Rehabilitation Science, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Hideaki Senjyu
- Department of Cardiopulmonary Rehabilitation Science, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Kenichiro Tanaka
- Department of Cardiopulmonary Rehabilitation Science, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Takako Tanaka
- Department of Cardiopulmonary Rehabilitation Science, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Masaharu Asai
- Department of Cardiopulmonary Rehabilitation Science, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Ryo Kozu
- Department of Rehabilitation Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Mitsuru Tabusadani
- Center for Industry, University and Government Cooperation, Nagasaki University, Nagasaki, Japan
| | - Sumihisa Honda
- Department of Cardiopulmonary Rehabilitation Science, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Terumitsu Sawai
- Department of Cardiopulmonary Rehabilitation Science, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
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Veterans with chronic obstructive pulmonary disease achieve clinically relevant improvements in respiratory health after pulmonary rehabilitation. J Cardiopulm Rehabil Prev 2015; 34:420-9. [PMID: 25166259 DOI: 10.1097/hcr.0000000000000079] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To measure respiratory health and respiratory-related (RR) health care utilization in veterans with chronic obstructive pulmonary disease referred to pulmonary rehabilitation (PR) at the Cincinnati Veterans Administration (VA) Medical Center. METHODS We reviewed the records of 430 patients referred for PR from 2008 to 2010: 78 met inclusion criteria and completed PR (PR group); 92 qualified for PR but declined participation (referral group). All PR participants completed the St. George's Respiratory Questionnaire (SGRQ), BODE index, 6-minute walk test (6MWT), UCSD Shortness of Breath Questionnaire (UCSDSOBQ), Pulmonary Disease Knowledge Test, and self-reported use of short-acting bronchodilators before and after PR. All VA health care encounters during the 12 months before and after PR (PR group) or referral (referral group) were reviewed. RESULTS Respiratory health improved after PR: SGRQ (60.6 ± 15.1, 51.1 ± 16.7), BODE (4.65 ± 1.93, 3.41 ± 1.84), 6MWT (497 ± 367 m, 572 ± 397 m), UCSDSOBQ (68.3 ± 21.1, 61.0 ± 20.9), Pulmonary Disease Knowledge Test (75.9 ± 12.4%, 85.9 ± 11.1%), short-acting bronchodilator (22.5 ± 25.3, 12.8 ± 15.6 inhalations per week) (before, after PR; P < .001 for all comparisons). The RR emergency department (ED) visits (0.71 ± 1.44, 0.44 ± 0.86; P = .04) and RR hospitalizations (0.41 ± 0.73, 0.23 ± 0.51; P = .03) (visits/patient/year; pre-PR, post-PR) decreased following PR. RR ED visits and hospitalizations were the same for the PR and referral groups prior to PR but declined post-PR (0.44 ± 0.86, 0.78 ± 1.36 ED visits/patient/year; P = .05) and (0.23 ± 0.51, 0.59 ± 1.20 hospitalizations/patient/year; P = .01). Ninety-four percent of PR participants achieved the minimal clinically important difference in at least 1 univariate scale (Modified Medical Research Council, UCSDSOBQ, SGRQ, and 6MWT); 82%, 2 scales; 59%, 3 scales; and 24%, all 4 scales. CONCLUSIONS Pulmonary rehabilitation improves respiratory health in veterans with chronic obstructive pulmonary disease and decreases RR health care utilization.
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Haun JN, Patel NR, French DD, Campbell RR, Bradham DD, Lapcevic WA. Association between health literacy and medical care costs in an integrated healthcare system: a regional population based study. BMC Health Serv Res 2015; 15:249. [PMID: 26113118 PMCID: PMC4482196 DOI: 10.1186/s12913-015-0887-z] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 05/22/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Low health literacy is associated with higher health care utilization and costs; however, no large-scale studies have demonstrated this in the Veterans Health Administration (VHA). This research evaluated the association between veterans' health literacy and their subsequent VHA health care costs across a three-year period. METHODS This retrospective study used a Generalized Linear Model to estimate the relative association between a patient's health literacy and VHA medical costs, adjusting for covariates. Secondary data sources included electronic health records and administrative data in the VHA (e.g., Medical and DCG SAS Datasets and DSS-National Data Extracts). Health literacy assessments and identifiers were electronically retrieved from the originating health system. Demographic and cost data were retrieved from the VHA centralized databases for the corresponding patients who had VHA use in all three years. RESULTS In a study of 92,749 veterans with service utilization from 2007-2009, average per patient cost for those with inadequate and marginal health literacy was significantly higher ($31,581 [95 % CI: $30,186 - $32,975]; $23,508 [95 % CI: $22,749 - $24,268]) than adequate health literacy ($17,033 [95 % CI: $16,810 - $17,255]). Estimated three-year cost associated with veterans' with marginal and inadequate health literacy was $143 million dollars more than those with adequate health literacy. CONCLUSIONS Analyses suggest when controlling for other person-level factors within the VHA integrated healthcare system, lower health literacy is a significant independent factor associated with increased health care utilization and costs. This study confirms the association of lower health literacy with higher medical service utilization and pharmacy costs for veterans enrolled in the VHA. Confirmation of higher costs of care associated with lower health literacy suggests that interventions might be designed to remediate health literacy needs and reduce expenditures. These analyses suggest 17.2 % (inadequate & marginal) of the Veterans in this population account for almost one-quarter (24 %) of VA medical and pharmacy cost for this 3-year period. Meeting the needs of those with marginal and inadequate health literacy could produce potential economic savings of approximately 8 % of total costs for this population.
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Affiliation(s)
- Jolie N Haun
- HSR&D Center of Innovation on Disability and Rehabilitation Research, James A. Haley Veterans Hospital, 8900 Grand Oak Circle (151R), Tampa, FL, 33637, USA.
- Department of Community & Family Health, University of South Florida College of Public Health, 13201 Bruce B. Downs Blvd. (MDC 56), Tampa, FL, 33612-3805, USA.
| | - Nitin R Patel
- HSR&D Center of Innovation on Disability and Rehabilitation Research, James A. Haley Veterans Hospital, 8900 Grand Oak Circle (151R), Tampa, FL, 33637, USA.
| | - Dustin D French
- Department of Ophthalmology and Center for Healthcare Studies and VA Center of Excellence, Northwestern University Feinberg School of Medicine, 645 N. Michigan Ave. Suite 440, Chicago, IL, 60611, USA.
| | - Robert R Campbell
- HSR&D Center of Innovation on Disability and Rehabilitation Research, James A. Haley Veterans Hospital, 8900 Grand Oak Circle (151R), Tampa, FL, 33637, USA.
| | - Douglas D Bradham
- Robert J Dole VAMC, 5500 East Kellogg Ave., Wichita, KS, 67218, USA.
- American Institutes for Research, Health and Social Development Program, Health Policy and Research Group, 1000 Thomas Jefferson Street, NW, Washington, DC, 20007-3835, USA.
| | - William A Lapcevic
- HSR&D Center of Innovation on Disability and Rehabilitation Research, James A. Haley Veterans Hospital, 8900 Grand Oak Circle (151R), Tampa, FL, 33637, USA.
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Abstract
Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. Age and smoking are common risk factors for COPD and other illnesses, often leading COPD patients to demonstrate multiple coexisting comorbidities. COPD exacerbations and comorbidities contribute to the overall severity in individual patients. Clinical trials investigating the treatment of COPD routinely exclude patients with multiple comorbidities or advanced age. Clinical practice guidelines for a specific disease do not usually address comorbidities in their recommendations. However, the management and the medical intervention in COPD patients with comorbidities need a holistic approach that is not clearly established worldwide. This holistic approach should include the specific burden of each comorbidity in the COPD severity classification scale. Further, the pharmacological and nonpharmacological management should also include optimal interventions and risk factor modifications simultaneously for all diseases. All health care specialists in COPD management need to work together with professionals specialized in the management of the other major chronic diseases in order to provide a multidisciplinary approach to COPD patients with multiple diseases. In this review, we focus on the major comorbidities that affect COPD patients. We present an overview of the problems faced, the reasons and risk factors for the most commonly encountered comorbidities, and the burden on health care costs. We also provide a rationale for approaching the therapeutic options of the COPD patient afflicted by comorbidity.
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Affiliation(s)
- Georgios Hillas
- Department of Critical Care and Pulmonary Services, University of Athens Medical School, Evangelismos Hospital, Athens, Greece
| | - Fotis Perlikos
- Department of Critical Care and Pulmonary Services, University of Athens Medical School, Evangelismos Hospital, Athens, Greece
| | - Ioanna Tsiligianni
- Department of Thoracic Medicine, University Hospital of Heraklion, Medical School, University of Crete, Crete, Greece
- Department of General Practice, University Medical Centre of Groningen, Groningen, The Netherlands
| | - Nikolaos Tzanakis
- Department of Thoracic Medicine, University Hospital of Heraklion, Medical School, University of Crete, Crete, Greece
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de Miguel Díez J, Jiménez García R, Hernández Barrera V, Puente Maestu L, Del Cura González MI, Méndez Bailón M, Carrasco Garrido P, López de Andrés A. Trends in self-rated health status and health services use in COPD patients (2006-2012). A Spanish population-based survey. Lung 2014; 193:53-62. [PMID: 25549895 DOI: 10.1007/s00408-014-9682-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Accepted: 12/21/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) patients often have a significant impairment in their health status, which is an independent predictor of health services use. OBJECTIVES To describe the self-rated health status and the prevalence of health services use among COPD Spanish patients; to identify which factors are independently associated with a worse health status and a higher use of health services; and to study the time trends in the health status and prevalence of use of health services (2006-2012). METHODS Observational study: We analyzed data from the Spanish National Health Surveys conducted in 2006 and 2012. We included responses from adults aged 40 years or over. Subjects described their health status as very good, good, fair, poor, or very poor, which was dichotomized into very good/good or fair/poor/very poor self-perceived health status. RESULTS We identified 2,321 COPD patients. The percentage of patients with health status fair, poor, or very poor was 76.8 % in 2006 and 74.8 % in 2012 (p > 0.05). Regarding the health resources use, we observed a significant decrease in the number of visits to primary care over time in women (67.8 vs. 57.2 %, p < 0.05) and men (62.2 vs. 54.0 %, p < 0.05). However, we did not find improvement in the prevalence of emergency department visits or hospitalizations. Associated factors with a worse self-rated health status and a higher use of health services in women and men included: having three or more chronic diseases, presence of mental disorders, and absence of leisure time physical activity. CONCLUSIONS The current study revealed a decrease in the general practitioner visits, without changes in use of other health care services in the COPD Spanish population from 2006 to 2012. The self-rated health status did not changed significantly during this period.
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Affiliation(s)
- Javier de Miguel Díez
- Department of Respiratory Medicine, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Universidad Complutense de Madrid, C/Doctor Esquerdo 46, 28007, Madrid, Spain,
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Mulhall AM, Lach LA, Krzywkowski-Mohn SM, Welge JA, Panos RJ. Therapeutic paralysis in veterans with COPD. Respir Med 2013; 107:1547-57. [PMID: 23827725 DOI: 10.1016/j.rmed.2013.05.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Revised: 05/27/2013] [Accepted: 05/30/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND Chronic Obstructive Pulmonary Disease (COPD) is a common disorder of Veterans that causes significant morbidity and mortality. To measure Veterans' perceptions about COPD, the effect of COPD on their lives and health, and their needs for improved health, we performed a postal survey. METHODS 3263 Veterans with a diagnosis of COPD who received care at the Cincinnati Veterans Affairs Medical Center in 2008 were stratified into quintiles by Veterans Health Administration-associated COPD healthcare cost and uniformly sampled. RESULTS 493 of 1000 surveys (49%) were completed and returned. COPD had different effects on respondents in top and bottom quintiles (highest and lowest COPD-related cost) for: knowledge of COPD diagnosis (89% vs. 73%, p = 0.03); activities affected by breathing, including work (69% vs. 45%), recreation (85% vs. 62%), change in living arrangements (36% vs 16%), and increased need for help (54% vs. 25%) (p < 0.05 for all comparisons); emotional effect of respiratory symptoms, including depression (53% vs. 30%), fear (41% vs. 15%), and helplessness (49% vs. 24%) (p < 0.05 for all comparisons). 91% of Veterans were prescribed inhalers and one-quarter had difficulties using them. 25% of Veterans did nothing when they had symptoms of an exacerbation. CONCLUSIONS COPD has profound effects on Veterans' breathing related activities and generates many negative emotions. Primary care providers are critical in conveying the diagnosis of COPD and providing information about the disease and its management. Veterans with COPD adhere poorly to their medications, and report little instruction about COPD or its management.
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Affiliation(s)
- Aaron M Mulhall
- Department of Internal Medicine, University of Cincinnati Academic Health Center, 231 Albert Sabin Way, Cincinnati, OH 45267, USA.
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