Socioeconomic deprivation increases the effect of winter on admissions to hospital with COPD: retrospective analysis of 10 years of national hospitalisation data

Arsenic exposure and lung function decline in chronic obstructive pulmonary disease patients: The mediating influence of systematic inflammation and oxidative stress

Lung tissue is one of the target sites of arsenic (As). The goal of this investigation was to assess the associations of blood As concentration with pulmonary function indicators in patients with chronic obstructive pulmonary disease (COPD), as well as the roles of systemic inflammation and oxidative stress in this relationship. All 791 COPD patients were selected. Blood As concentration, and tumour necrosis factor-α (TNF-α) and 8-iso-prostaglandin-F2α (8-iso-PGF2α) were detected in the serum of COPD cases. Blood As was robustly related to pulmonary function parameters in an inverse dose-dependent manner. Multivariate linear regression analyses verified that a 1-unit increase of blood As was linked to declines of 0.263 L in FVC, 0.288 L in FEV1, 3.454 in FEV1/FVC%, and 0.538 in predicted FEV1%, respectively. The potential for pulmonary function decline gradually increased across the elevated tertiles of blood As. Nonsmokers were susceptible to As-induced pulmonary function reduction. Blood As was positively linked to the levels of TNF-α and 8-iso-PGF2α. Increased TNF-α and 8-iso-PGF2α partially mediated As-induced the reductions in FEV1 and FVC among COPD patients. As exposure is intensely linked to pulmonary function reduction. Systematic inflammation and oxidative stress partially mediate such associations in COPD patients.

Spatiotemporal relationship between temperature and non-accidental mortality: Assessing effect modification by socioeconomic status

BACKGROUND

Most published studies have assessed the overall health impact of temperature by using one-station or multiple-station averaged meteorological and air quality data. Concern has arisen about whether the temperature health impact is homogeneous across the whole territory geographically, since green space and socioeconomic factors may modify the impact.

OBJECTIVE

This study aims at investigating how small-area mortality is modified by local temperature and other meteorological, air quality, green space, and socioeconomic factors of small geographic units in a subtropical urban setting.

METHODS

Data on meteorological, air pollutants, and non-accidental mortality count in Hong Kong during 2006-2016 were obtained. Combined with green space and socioeconomic data, spatiotemporal analysis using Generalized Additive Mixed Models was conducted to examine the temperature-mortality relationship, adjusted for seasonality, long-term trend, other meteorological factors, pollutants, socioeconomic characteristics and green space.

RESULTS

Socioeconomic status was found to modify the temporal temperature-mortality relationship. A J-shape association was identified for most areas in Hong Kong, where a sharp increase of mortality was observed when daily minimum temperature dropped lower than the turning point. However, for people living in the most affluent areas, after the initial increase there was a decrease of mortality for colder days. Besides, when comparing the two spatiotemporal models (i.e. using nearby or central temperature monitoring station), while leaving the other predictors unchanged, this study showed that there was little difference in the overall model performances.

CONCLUSION

This study indicated that the daily fluctuation of mortality was associated with daily temperature, while the spatial variation of mortality within this city could be explained by the geographical distribution of green space and socioeconomic factors. Since people living in affluent areas were found to be more tolerant of cold temperatures, it would be more efficient to tailor cold temperature health education and warning information for socioeconomically deprived communities.

Association of Chronic Lower Respiratory Disease With County Health Disparities in New York State

IMPORTANCE

Chronic lower respiratory disease (CLRD) is the fourth leading cause of death in the United States, which imposes a considerable burden on individuals, families, and societies. The association between county-level health disparity and CLRD outcomes in New York state needs investigation.

OBJECTIVE

To evaluate the associations of CLRD outcomes with county-level health disparities in New York state.

DESIGN, SETTING, AND PARTICIPANTS

In this cross-sectional study, CLRD age-adjusted hospitalization for 2016 and mortality rates from 2014 to 2016 were obtained from the New York state Community Health Indicator Reports provided by the New York state Department of Health. County Health Rankings were used to evaluate various health factors to provide a summary z score for each county representing the county health status and how that county ranks in the state. Data analysis was performed from November 2020 to March 2021.

MAIN OUTCOMES AND MEASURES

The main outcomes were age-adjusted hospitalization and mortality rates for CLRD. The z score was calculated from the County Health Rankings, which includes subindicators of health behaviors, clinical care, social and economic factors, and physical environment. Pearson r and linear regression models were estimated.

RESULTS

During the study, 60 335 discharges were documented as CLRD hospitalizations in 2016 and 20 612 people died from CLRD from 2014 to 2016 in New York state. After adjusting for age, the CLRD hospitalization rate was 27.6 per 10 000 population, and the mortality rate was 28.9 per 100 000 population. Among 62 counties, Bronx had the highest hospitalization rate (64.7 per 10 000 population) whereas Hamilton had the lowest hospitalization rate (6.6 per 10 000 population). Mortality rates ranged from 17.4 per 100 000 population in Kings to 62.9 per 100 000 population in Allegany. County Health Rankings indicated Nassau had the lowest z score (the healthiest), at -1.17, but Bronx had the highest z score (the least healthy), at 1.43, for overall health factors in 2018. An increase of 1 point in social and economic factors z score was associated with an increase of 17.6 hospitalizations per 10 000 population (β = 17.61 [95% CI, 10.36 to 24.87]; P < .001). A 1-point increase in health behaviors z score was associated with an increase of 41.4 deaths per 100 000 population (β = 41.42 [95% CI, 29.88 to 52.97]; P < .001).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, CLRD outcomes were significantly associated with county-level health disparities in New York state. These findings suggest that public health interventions and resources aimed at improving CLRD outcomes should be tailored and prioritized in health disadvantaged areas.

Impact of social isolation on mortality and morbidity in 20 high-income, middle-income and low-income countries in five continents

Objective

To examine the association between social isolation and mortality and incident diseases in middle-aged adults in urban and rural communities from high-income, middle-income and low-income countries.

Design

Population-based prospective observational study.

Setting

Urban and rural communities in 20 high income, middle income and low income.

Participants

119 894 community-dwelling middle-aged adults.

Main outcome measures

Associations of social isolation with mortality, cardiovascular death, non-cardiovascular death and incident diseases.

Results

Social isolation was more common in middle-income and high-income countries compared with low-income countries, in urban areas than rural areas, in older individuals and among women, those with less education and the unemployed. It was more frequent among smokers and those with a poorer diet. Social isolation was associated with greater risk of mortality (HR of 1.26, 95% CI: 1.17 to 1.36), incident stroke (HR: 1.23, 95% CI: 1.07 to 1.40), cardiovascular disease (HR: 1.15, 95% CI: 1.05 to 1.25) and pneumonia (HR: 1.22, 95% CI: 1.09 to 1.37), but not cancer. The associations between social isolation and mortality were observed in populations in high-income, middle-income and low-income countries (HR (95% CI): 1.69 (1.32 to 2.17), 1.27 (1.15 to 1.40) and 1.47 (1.25 to 1.73), respectively, interaction p=0.02). The HR associated with social isolation was greater in men than women and in younger than older individuals. Mediation analyses for the association between social isolation and mortality showed that unhealthy behaviours and comorbidities may account for about one-fifth of the association.

Conclusion

Social isolation is associated with increased risk of mortality in countries at different economic levels. The increasing share of older people in populations in many countries argues for targeted strategies to mitigate its adverse effects.

Operational Modeling with Health Economics to Support Decision Making for COPD Patients

OBJECTIVE

To assess the impact of interventions for improving the management of chronic obstructive pulmonary disease (COPD), specifically increased use of pulmonary rehabilitation (PR) on patient outcomes and cost-benefit analysis.

DATA SOURCES

We used the national Hospital Episode Statistics (HES) datasets in England, local data and experts from the hospital setting, National Prices and National Tariffs, reports and the literature around the effectiveness of PR programs.

STUDY DESIGN

The COPD pathway was modeled using discrete event simulation (DES) to capture the patient pathway to an adequate level of detail as well as randomness in the real world. DES was further enhanced by the integration of a health economic model to calculate the net benefit and cost of treating COPD patients based on key sets of interventions.

DATA COLLECTION/EXTRACTION METHODS

A total of 150 input parameters and 75 distributions were established to power the model using the HES dataset, outpatient activity data from the hospital and community services, and the literature.

PRINCIPAL FINDINGS

The simulation model showed that increasing referral to PR (by 10%, 20%, or 30%) would be cost-effective (with a benefit-cost ratio of 5.81, 5.95, and 5.91, respectively) by having a positive impact on patient outcomes and operational metrics. Number of deaths, admissions, and bed days decreased (ie, by 3.56 patients, 4.90 admissions, and 137.31 bed days for a 30% increase in PR referrals) as well as quality of life increased (ie, by 5.53 QALY among 1540 patients for the 30% increase).

CONCLUSIONS

No operational model, either statistical or simulation, has previously been developed to capture the COPD patient pathway within a hospital setting. To date, no model has investigated the impact of PR on COPD services, such as operations, key performance, patient outcomes, and cost-benefit analysis. The study will support policies around extending availability of PR as a major intervention.

A modelling framework for developing early warning systems of COPD emergency admissions

Chronic Obstructive Pulmonary Disease (COPD) is one of the leading causes of mortality worldwide and is a major contributor to the number of emergency admissions in the UK. We introduce a modelling framework for the development of early warning systems for COPD emergency admissions. We analyse the number of COPD emergency admissions using a Poisson generalised linear mixed model. We group risk factors into three main groups, namely pollution, weather and deprivation. We then carry out variable selection within each of the three domains of COPD risk. Based on a threshold of incidence rate, we then identify the model giving the highest sensitivity and specificity through the use of exceedance probabilities. The developed modelling framework provides a principled likelihood-based approach for detecting the exceedance of thresholds in COPD emergency admissions. Our results indicate that socio-economic risk factors are key to enhance the predictive power of the model.

The effect of air-pollution and weather exposure on mortality and hospital admission and implications for further research: A systematic scoping review

BACKGROUND

Air-pollution and weather exposure beyond certain thresholds have serious effects on public health. Yet, there is lack of information on wider aspects including the role of some effect modifiers and the interaction between air-pollution and weather. This article aims at a comprehensive review and narrative summary of literature on the association of air-pollution and weather with mortality and hospital admissions; and to highlight literature gaps that require further research.

METHODS

We conducted a scoping literature review. The search on two databases (PubMed and Web-of-Science) from 2012 to 2020 using three conceptual categories of "environmental factors", "health outcomes", and "Geographical region" revealed a total of 951 records. The narrative synthesis included all original studies with time-series, cohort, or case cross-over design; with ambient air-pollution and/or weather exposure; and mortality and/or hospital admission outcomes.

RESULTS

The final review included 112 articles from which 70 involved mortality, 30 hospital admission, and 12 studies included both outcomes. Air-pollution was shown to act consistently as risk factor for all-causes, cardiovascular, respiratory, cerebrovascular and cancer mortality and hospital admissions. Hot and cold temperature was a risk factor for wide range of cardiovascular, respiratory, and psychiatric illness; yet, in few studies, the increase in temperature reduced the risk of hospital admissions for pulmonary embolism, angina pectoris, chest, and ischemic heart diseases. The role of effect modification in the included studies was investigated in terms of gender, age, and season but not in terms of ethnicity.

CONCLUSION

Air-pollution and weather exposure beyond certain thresholds affect human health negatively. Effect modification of important socio-demographics such as ethnicity and the interaction between air-pollution and weather is often missed in the literature. Our findings highlight the need of further research in the area of health behaviour and mortality in relation to air-pollution and weather, to guide effective environmental health precautionary measures planning.

Findings from a pilot randomised trial of a social network self-management intervention in COPD

BACKGROUND

Self-Management Support (SMS), refers to the actions taken by individuals to recognise and manage their own health. It is increasingly recognised that individuals with chronic obstructive pulmonary disease (COPD) require additional support with their Self-management. Emerging evidence suggests that the use of a social network intervention can improve health outcomes and increase quality of life. In order to understand the potential benefits of SMS in COPD, the GENIE (Generating Engagement in Network Support) SMS tool was implemented and evaluated in a COPD primary care context. The GENIE intervention is a social networking tool that consists of 3 parts; a concentric circle modelling to map existing social networks; a questions sections to elicit preferences for activities; a map of selected resources is then produced, aligned with the user's interests and suggestions for connections to existing network members and to new resources.

METHODS

A pilot, parallel, single blind, block randomised controlled trial. Patients with COPD ranging from mild-very severe were recruited. Participants provided written consent and were then randomised to either the intervention or usual care. The primary aim was to understand the clinical benefit through the analysis of health status, symptom burden and quality of life. The secondary outcome measure was health utilisation. NHS cost differences were reported between groups using the GENIE intervention over usual care.

RESULTS

The GENIE pilot results demonstrate maintenance in health status and clinical symptoms with a decrease in anxiety. An overall increase in quality of life was observed, these findings did not reach significance. A cost reduction was demonstrated in inpatient stay with no difference in primary care costs. Overall a cost reduction in NHS service utilisation was indicated in the intervention group.

CONCLUSION

This pilot study indicated that using a social network intervention can encourage the development of new social connections and extend existing support networks for COPD patients. Increasing network support in this population is of benefit to both patients and NHS providers in terms of cost reductions and enhancing wellbeing. This broadens the understanding of possible new approaches to SMS in community COPD patients, which could now be investigated in a larger population over a longer period.

TRIAL REGISTRATION

Clinical Trials.gov PRS National Library of Medicine. Protocol ID number: 19175, Clinical Trial ID: NCT02935452.

Do hospital admission rates increase in colder winters? A decadal analysis from an eastern county in England

Background

The aim of the study was to measure the effect of colder winters compared to warmer winters on hospital admission rates in Suffolk County.

Methods

The setting of this study was Suffolk County in eastern England. The period of the study was financial years 2003/04-2012/13. The study was an analytic ecological study. Analysis involved calculation of rate ratios of hospital admission rates in colder winters compared to warmer winters, in all persons and the elderly.

Results

The main finding of the study was that all rate ratios for hospital admission rates in colder winters compared to warmer winters were significantly raised with effects of 2-5%. Rate ratios for all admissions in persons of all ages and persons aged 65 years and over were, respectively, 1.02 (99% confidence interval (CI): 1.01, 1.03; P < 0.001) and 1.02 (99% CI: 1.01, 1.04; P < 0.001). Rate ratios for emergency admissions in persons of all ages and persons aged 65 years and over were, respectively, 1.05 (99% CI: 1.03, 1.06; P < 0.001) and 1.04 (99% CI: 1.01, 1.06; P < 0.001).

Conclusion

In Suffolk County, hospital admission rates are significantly raised in colder winters compared to warmer winters. This evidence may be useful in planning hospital services.

Influence Of Socioeconomic Deprivation On Short- And Long-Term Outcomes Of Home-Based Pulmonary Rehabilitation In Patients With Chronic Obstructive Pulmonary Disease

Background

Pulmonary rehabilitation (PR) improves exercise tolerance and quality of life in patients with chronic obstructive pulmonary disease (COPD), regardless of disease severity. Socioeconomic deprivation has been linked to the incidence of COPD; however, little is known about its impact on PR outcomes.

Methods

In this retrospective observational study, 459 COPD patients were enrolled and dichotomized into socially deprived (n=276) and non-socially deprived (n=183) groups based on a cut-off of 30.17 in the EPICES questionnaire (Evaluation of Deprivation and Inequalities in Health Centers), which evaluates socioeconomic disadvantage. The PR program consisted of once-weekly home sessions for 8 weeks, and consisted of an individualized plan of retraining exercises, physical activities, therapeutic education, and psychosocial and motivational support. Exercise tolerance, anxiety and depression, and quality of life were assessed using the 6 min stepper test (6MST), Hospital Anxiety and Depression Scale (HADS), and Visual Simplified Respiratory Questionnaire (VSRQ). Assessments were made before the PR program (baseline) and then at 2 (T2), 8 (T8), and 14 (T14) months after baseline.

Results

Compared with the non-socially deprived group, socially deprived patients were younger, more frequently women, active smokers, and living alone, and belonged to lower socioprofessional categories. At baseline, 6MST, VSRQ, and HADS measures were lower for the socially deprived than the non-socially deprived group. At T2, T8, and T14, there were no significant between-group differences in any outcome, and the percentage of patients showing clinically important improvements was the same in both groups.

Conclusion

Home-based PR is effective for COPD patients in the short and long term, regardless of socioeconomic status.

Winter Is Coming: A Socio-Environmental Monitoring and Spatiotemporal Modelling Approach for Better Understanding a Respiratory Disease

Chronic Obstructive Pulmonary Disease is a progressive lung disease affecting the respiratory function of every sixth New Zealander and over 300 million people worldwide. In this paper, we explored how the combination of social, demographical and environmental conditions (represented by increased winter air pollution) affected hospital admissions due to COPD in an urban area of Christchurch (NZ). We juxtaposed the hospitalisation data with dynamic air pollution data and census data to investigate the spatiotemporal patterns of hospital admissions. Spatial analysis identified high-risk health hot spots both overall and season specific, exhibiting higher rates in winter months not solely due to air pollution, but rather as a result of its combination with other factors that initiate deterioration of breathing, increasing impairments and lead to the hospitalisation of COPD patients. From this we found that socioeconomic deprivation and air pollution, followed by the age and ethnicity structure contribute the most to the increased winter hospital admissions. This research shows the continued importance of including both individual (composition) and area level (composition) factors when examining and analysing disease patterns.

A non-randomised controlled pilot study of clinical pharmacist collaborative intervention for community dwelling patients with COPD

UK, home-based patients with COPD receive specialist care from respiratory physicians, nurses, and general practitioners (GPs), but increasing complexity of therapeutic options and a GP/Nurse workforce crisis suggests merit in testing the role of home visits by a clinical pharmacist. We conducted a non-randomised intervention study with a contemporaneous comparator group, in Glasgow (Scotland). A clinical pharmacist (working closely with a consultant respiratory physician) visited patients with COPD living at home, assessing respiratory and other co-morbid conditions, and medicines then, with patient approval, agreed treatment modifications with a consultant physician. Comparator group-patients were drawn from another hospital out-patient clinic. Main outcomes were exacerbations during 4-months of follow-up and respiratory hospitalisations (number and duration) after 1 year. In the intervention group, 86 patients received a median of three home visits; 87 received usual care (UC). At baseline, patients in the intervention group were similar to those in UC in terms of respiratory hospitalisations although slightly younger, more likely to receive specific maintenance antibiotics/Prednisolone and to have had exacerbations. Sixty-two (72.1%) of the intervention group received dose changes; 45 (52.3%) had medicines stopped/started and 21 (24.4%) received an expedited review at the specialist respiratory consultant clinic; 46 (53.5%) were referred to other healthcare services. Over one-third were referred for bone scans and 11% received additional investigations. At follow-up, 54 (63.5%) of intervention group participants had an exacerbation compared with 75 (86.2%) in the UC group (p = 0.001); fewer had respiratory hospitalisations (39 (45.3%) vs. 66 (76.7%); p < 0.001). Hospitalisations were shorter in the intervention group. Pharmacist-consultant care for community dwelling patients with COPD, changed clinical management and improved outcomes. A randomised controlled trial would establish causality.

Clinical pharmacists, working in collaboration with respiratory specialists, can help people who live at home with chronic obstructive pulmonary disease (COPD) better manage their medications and symptoms. In a non-randomised pilot study, Richard Lowrie from the NHS Greater Glasgow and Clyde,
UK, and colleagues found that patients with COPD who receive standard at-home care—which includes visits to GP surgeries and hospital-based respiratory out-patient clinics, and visits from respiratory specialist nurses—were more likely to experience exacerbations and need lengthy hospital stays than those who additionally received home visits from a clinical pharmacist. The pharmacist, in consultation with the patient’s respiratory physician, often proposed medication changes and suggested additional testing or referrals that presumably explain the improved health outcomes. The authors conclude that a large, randomised trial is warranted to further evaluate the merits of this collaborative intervention for community dwelling patients with COPD.

A time for everything and everything in its time - exploring the mechanisms underlying seasonality of COPD exacerbations

Across Europe, COPD affects 23 million people leading to annual health care costs of ~€25.1 billion. This burden is particularly severe during winter months in association with the peak incidence of exacerbation events. Seasonal variation in the health status of patients with COPD places additional and often critical pressure on already strained health care resources. COPD exacerbations are characterized by worsening day-to-day symptoms of an individual and often triggered by respiratory infections, but the process by which this occurs in a seasonal fashion is likely to be multifactorial. In this review, we discuss recent population studies that highlight the impact of seasonality in COPD and review the proposed biological mechanisms underlying this. An appraisal of the role of the host susceptibility and response, environmental triggers and the biology of respiratory pathogens is detailed. The impact of each aspect is considered, and an integrated model of the context for the whole individual and society in general is explored.

Which patients with advanced respiratory disease die in hospital? A 14-year population-based study of trends and associated factors

BACKGROUND

Strategies in many countries have sought to improve palliative care and reduce hospital deaths for non-cancer patients, but their effects are not evaluated. We aimed to determine the trends and factors associated with dying in hospital in two common progressive respiratory diseases, and the impact of a national end of life care (EoLC) strategy to reduce deaths in hospital.

METHODS

This population-based observational study linked death registration data for people in England dying from chronic obstructive pulmonary disease (COPD) or interstitial pulmonary diseases (IPD). We plotted age- and sex-standardised trends, assessed during the pre-strategy (2001-2004), first strategy phase (2004-2008), and strategy intensification (2009-2014) periods, and identified factors associated with hospital death using multiple adjusted proportion ratios (PRs).

RESULTS

Over 14 years, 380,232 people died from COPD (334,520) or IPD (45,712). Deaths from COPD and IPD increased by 0.9% and 9.2% annually, respectively. Death in hospital was most common (67% COPD, 70% IPD). Dying in hospice was rare (0.9% COPD, 2.9% IPD). After a plateau in 2004-2005, hospital deaths fell (PRs 0.92-0.94). Co-morbidities and deprivation independently increased the chances of dying in hospital, with larger effects in IPD (PRs 1.01-1.55) than COPD (PRs 1.01-1.39) and dose-response gradients. The impact of multimorbidity increased over time; hospital deaths did not fall for people with two or more co-morbidities in COPD, nor one or more in IPD. Living in rural areas (PRs 0.94-0.94) or outside London (PRs, 0.89-0.98) reduced the chances of hospital death. In IPD, increased age reduced the likelihood of hospital death (PR 0.81, ≥ 85 versus ≤ 54 years); divergently, in COPD, being aged 65-74 years was associated with increased hospital deaths (PR 1.13, versus ≤ 54 years). The independent effects of sex and marital status differed for COPD versus IPD (PRs 0.89-1.04); in COPD, hospital death was associated with being married.

CONCLUSIONS

The EoLC strategy appeared to have contributed to tangible reductions in hospital deaths, but did not reach people with multimorbidity and this gap widened over time. Integrating palliative care earlier in the disease trajectory especially in deprived areas and cities, and where multimorbidity is present, should be boosted, taking into account the different demographic factors in COPD and IPD.

Socioeconomic deprivation and the outcome of pulmonary rehabilitation in England and Wales

Background

Pulmonary rehabilitation (PR) improves exercise capacity and health status in patients with COPD, but many patients assessed for PR do not complete therapy. It is unknown whether socioeconomic deprivation associates with rates of completion of PR or the magnitude of clinical benefits bequeathed by PR.

Methods

PR services across England and Wales enrolled patients to the National PR audit in 2015. Deprivation was assessed using Index of Multiple Deprivation (IMD) derived from postcodes. Study outcomes were completion of therapy and change in measures of exercise performance and health status. Univariate and multivariate analyses investigated associations between IMD and these outcomes.

Results

210 PR programmes enrolled 7413 patients. Compared with the general population, the PR sample lived in relatively deprived neighbourhoods. There was a statistically significant association between rates of completion of PR and quintile of deprivation (70% in the least and 50% in the most deprived quintiles). After baseline adjustments, the risk ratio (95% CI) for patients in the most deprived relative to the least deprived quintile was 0.79 (0.73 to 0.85), p<0.001. After baseline adjustments, IMD was not significantly associated with improvements in exercise performance and health status.

Conclusions

In a large national dataset, we have shown that patients living in more deprived areas are less likely to complete PR. However, deprivation was not associated with clinical outcomes in patients who complete therapy. Interventions targeted at enhancing referral, uptake and completion of PR among patients living in deprived areas could reduce morbidity and healthcare costs in such hard-to-reach populations.

Defining and targeting health disparities in chronic obstructive pulmonary disease

The global burden of chronic obstructive pulmonary disease (COPD) continues to grow in part due to better outcomes in other major diseases and in part because a substantial portion of the worldwide population continues to be exposed to inhalant toxins. However, a disproportionate burden of COPD occurs in people of low socioeconomic status (SES) due to differences in health behaviors, sociopolitical factors, and social and structural environmental exposures. Tobacco use, occupations with exposure to inhalant toxins, and indoor biomass fuel (BF) exposure are more common in low SES populations. Not only does SES affect the risk of developing COPD and etiologies, it is also associated with worsened COPD health outcomes. Effective interventions in these people are needed to decrease these disparities. Efforts that may help lessen these health inequities in low SES include 1) better surveillance targeting diagnosed and undiagnosed COPD in disadvantaged people, 2) educating the public and those involved in health care provision about the disease, 3) improving access to cost-effective and affordable health care, and 4) markedly increasing the efforts to prevent disease through smoking cessation, minimizing use and exposure to BF, and decreasing occupational exposures. COPD is considered to be one the most preventable major causes of death from a chronic disease in the world; therefore, effective interventions could have a major impact on reducing the global burden of the disease, especially in socioeconomically disadvantaged populations.

Housing as a Social Determinant of Health in Singapore and Its Association with Readmission Risk and Increased Utilization of Hospital Services

BACKGROUND

Residence in public rental housing is an area-level measure of socioeconomic status, but its impact as a social determinant of health in Singapore has not been studied. We therefore aimed to examine the association of public rental housing with readmission risk and increased utilization of hospital services in Singapore.

METHODS

We conducted a retrospective cohort study using retrospective 2014 data from Singapore General Hospital's electronic health records. Variables known to affect readmission risk and health-care utilization were identified a priori and include patient demographics, comorbidities, health-care utilization in the preceding 1 year and clinical variables from the index admission in 2014. Multivariate logistic regression was used to evaluate public rental housing as an independent risk factor for admission risk, emergency department (ED), and specialist outpatient clinic attendances.

RESULTS

A total of 14,457 unique patients were analyzed, and 2,163 patients (15.0%) were rental housing residents. Rental housing patients were significantly more likely to be male; required financial assistance; have chronic obstructive pulmonary disease; usage of anti-depressant and anti-psychotic medications; longer length of hospital stay during the index admission; and higher Charlson Comorbidity Index scores. After adjusting for demographics and clinical variables, staying in public rental housing remained an independent risk factor for readmission within 15 and 30 days, frequent hospital admissions and ED attendances in Singapore.

CONCLUSION

Our study showed an association between public rental housing with readmission risk and increased utilization of hospital services in Singapore. A deeper understanding of the residents' social circumstances and health seeking behavior would be insightful.

Effects of individual and neighborhood socioeconomic status on the risk of all-cause mortality in chronic obstructive pulmonary disease: A nationwide population-based cohort study, 2002-2013

BACKGROUND

Numerous previous studies have shown that individual socioeconomic status (SES) is associated with mortality in patients with chronic obstructive pulmonary disease (COPD), but few empirical studies have evaluated the effects of individual SES and neighborhood deprivation on mortality in COPD patients.

METHODS

We performed a prospective cohort study to examine the effect of socioeconomic disparity on all-cause mortality in newly diagnosed COPD patients in a setting with universal health care coverage. We used representative population-based nationwide cohort data from the Korean National Health Insurance claims database (2002-2013). We included patients who were at least 40 years old and newly diagnosed with COPD (N = 9275). To analyze the data, we utilized a frailty model and Cox's proportional hazard regression.

RESULTS

A total of 1849 (19.9%) of the 9275 eligible participants died during the study period. Compared to high-income patients from advantaged neighborhoods, the adjusted hazard ratio (HR) for middle-income COPD patients who lived in advantaged and disadvantaged neighborhoods was 1.22 (95% CI, 1.03-1.43) and 1.36 (95% CI, 1.15-1.60), respectively. For low-income patients, the adjusted HR for patients who lived in disadvantaged neighborhoods was higher than for patients who lived in advantaged neighborhoods (HR, 1.43; 95% CI, 1.17-1.74 vs. HR, 1.36; 95% CI, 1.11-1.66). There was no difference in the adjusted HRs for high-income patients who lived in advantaged and disadvantaged neighborhoods (HR, 1.01; 95% CI, 0.84-1.22).

CONCLUSIONS

Socioeconomic disparity contributes to all-cause mortality in COPD patients and neighborhood deprivation exacerbates the effect of individual SES on all-cause mortality in COPD patients.

The impact of communicating information about air pollution events on public health

Short-term exposure to air pollution has been associated with exacerbation of asthma and chronic obstructive pulmonary disease (COPD). This study investigated the relationship between emergency hospital admissions for asthma, COPD and episodes of poor air quality in an English city (Southampton) from 2008-2013. The city's council provides a forecasting service for poor air quality to individuals with respiratory disease to reduce preventable admissions to hospital and this has been evaluated. Trends in nitrogen dioxide, ozone and particulate matter concentrations were related to hospital admissions data using regression analysis. The impacts of air quality on emergency admissions were quantified using the relative risks associated with each pollutant. Seasonal and weekly trends were apparent for both air pollution and hospital admissions, although there was a weak relationship between the two. The air quality forecasting service proved ineffective at reducing hospital admissions. Improvements to the health forecasting service are necessary to protect the health of susceptible individuals, as there is likely to be an increasing need for such services in the future.

Mortality following Stroke, the Weekend Effect and Related Factors: Record Linkage Study

Background

Increased mortality following hospitalisation for stroke has been reported from many but not all studies that have investigated a ‘weekend effect’ for stroke. However, it is not known whether the weekend effect is affected by factors including hospital size, season and patient distance from hospital.

Objective

To assess changes over time in mortality following hospitalisation for stroke and how any increased mortality for admissions on weekends is related to factors including the size of the hospital, seasonal factors and distance from hospital.

Methods

A population study using person linked inpatient, mortality and primary care data for stroke from 2004 to 2012. The outcome measures were, firstly, mortality at seven days and secondly, mortality at 30 days and one year.

Results

Overall mortality for 37 888 people hospitalised following stroke was 11.6% at seven days, 21.4% at 30 days and 37.7% at one year. Mortality at seven and 30 days fell significantly by 1.7% and 3.1% per annum respectively from 2004 to 2012. When compared with week days, mortality at seven days was increased significantly by 19% for admissions on weekends, although the admission rate was 21% lower on weekends. Although not significant, there were indications of increased mortality at seven days for weekend admissions during winter months (31%), in community (81%) rather than large hospitals (8%) and for patients resident furthest from hospital (32% for distances of >20 kilometres). The weekend effect was significantly increased (by 39%) for strokes of ‘unspecified’ subtype.

Conclusions

Mortality following stroke has fallen over time. Mortality was increased for admissions at weekends, when compared with normal week days, but may be influenced by a higher stroke severity threshold for admission on weekends. Other than for unspecified strokes, we found no significant variation in the weekend effect for hospital size, season and distance from hospital.

Seasonality, ambient temperatures and hospitalizations for acute exacerbation of COPD: a population-based study in a metropolitan area

BACKGROUND

Excluding the tropics, exacerbations of chronic obstructive pulmonary disease (COPD) are more frequent in winter. However, studies that directly relate hospitalizations for exacerbation of COPD to ambient temperature are lacking. The aim of this study was to assess the influence of temperature on the number of hospitalizations for COPD.

METHODS

This was a population-based study in a metropolitan area. All hospital discharges for acute exacerbation of COPD during 2009 in Barcelona and its metropolitan area were analyzed. The relationship between the number of hospitalizations for COPD and the mean, minimum, and maximum temperatures alongside comorbidity, humidity, influenza rate, and environmental pollution were studied.

RESULTS

A total of 9,804 hospitalization discharges coded with COPD exacerbation as a primary diagnosis were included; 75.4% of cases were male with a mean age of 74.9±10.5 years and an average length of stay of 6.5±6.1 days. The highest number of admissions (3,644 [37.2%]) occurred during winter, followed by autumn with 2,367 (24.1%), spring with 2,347 (23.9%), and summer with 1,446 (14.7%; P<0.001). The maximum, minimum, and mean temperatures were associated similarly with the number of hospitalizations. On average, we found that for each degree Celsius decrease in mean weekly temperature, hospital admissions increased by 5.04% (r(2)=0.591; P<0.001). After adjustment for humidity, comorbidity, air pollution, and influenza-like illness, only mean temperatures retained statistical significance, with a mean increase of 4.7% in weekly admissions for each degree Celsius of temperature (r(2)=0.599, P<0.001).

CONCLUSION

Mean temperatures are closely and independently related to the number of hospitalizations for COPD.

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

BACKGROUND

Healthy Outlook is a service delivered by the UK Met Office directly to patients with chronic obstructive pulmonary disease (COPD) that has been in place since 2006. Its objective is to reduce the severity and length of COPD exacerbations, hence improving the quality of life and life expectancy.

AIMS

To assess the effect of the Healthy Outlook service on hospital admission rates of all general practitioners that have used the service.

METHODS

Control practices were selected for each of the 661 participating practices. The number of hospital admissions for each practice was extracted from the Hospital Episode Statistics database. The differences in admission rates per practice between the first year of use of the Healthy Outlook service and the previous year were compared by paired t-test analyses.

RESULTS

For admissions with a primary diagnosis of COPD, the difference between participating and control practices was -0.8% (95% confidence interval (CI)=-1.8 to 0.2%; P=0.13). For admissions with a primary or co-morbid diagnosis of COPD, the difference was -2.3% (95% CI=-4.2 to -0.4%; P=0.02).

CONCLUSIONS

Participation in the Healthy Outlook service reduces hospital admission rates for patients coded on discharge with COPD (including co-morbid).

The causes and consequences of seasonal variation in COPD exacerbations

The time of year when patients experience exacerbations of chronic obstructive pulmonary disease is a much-overlooked feature of the disease. The higher incidence of exacerbations in winter has important consequences for patients in terms of increased morbidity and mortality. The seasonality also imposes a considerable burden on already-overloaded health care services, with both primary care consultations and hospital admissions increasing in number. The seasonality of exacerbations varies with latitude, and is greater in more temperate climates, where there may be less protection from outdoor and indoor cold exposure. The precise causes of the seasonality are unknown, but thought to be partly due to the increased prevalence of respiratory viral infections circulating in cold, damp conditions. Increased susceptibility to viral infection may also be a mechanism mediated through increased airway inflammation or possibly reduced vitamin D levels. The seasonality of exacerbations informs us about the triggers of exacerbations and suggests possible strategies to reduce their number.