Clinical characteristics and risk of all-cause mortality in low education patients with chronic obstructive pulmonary disease in the Chinese population

Clinical characteristics and outcomes of chronic obstructive pulmonary disease patients with family history of chronic airway disease

BACKGROUND

Chronic Obstructive Pulmonary Disease (COPD) is a heterogeneous condition with different risk factors, including family history. This study aimed to explore association between a family history of chronic airway disease and features and outcomes of COPD.

METHODS

Participants were obtained from the RealDTC study between December 2016 and December 2022. Data on demographics, pulmonary function, history of exacerbation at baseline, acute exacerbation during 1-year follow-up and survival status during 3-years follow-up were collected.

RESULTS

5020 patients were enrolled, with 1307 patients (26.0%) having a family history of chronic airway diseases. Compared with patients without a family history of chronic airway diseases, patients with a family history had a lower forced expiratory Volume in one second (FEV1), higher Modified Medical Research Council (mMRC) score and COPD Assessment Test (CAT) score, higher rate of acute exacerbation and hospitalization in the past year (p < 0.05) and rate of acute exacerbation and hospitalization during 1 year follow-up period (p < 0.05). It was an independent risk factor for acute exacerbation (OR = 2.196; 95% CI =1.873-2.576) and hospitalization (OR = 2.199; 95% CI =1.812-2.670). Over 3 years of follow-up, there were no significant differences in mortality rates and annual changes in FEV1 between two groups.

CONCLUSION

COPD patients with a family history of chronic airway disease are not rare, and they tend to have more severe symptoms and a higher risk of future deterioration. In the management of COPD, special attention should be paid to patients with a family history of chronic airway disease.

Social determinants of health on all-cause and cause-specific mortality in US adults with chronic obstructive pulmonary disease: NHANES 2005-2018

BACKGROUND

Social determinants of health (SDoH) are nonmedical societal factors that influence health outcomes. However, their relationship with mortality risk in patients with chronic obstructive pulmonary disease (COPD) remains poorly understood. This study aimed to evaluate the association between SDoH and the risk of all-cause and cause-specific mortality in COPD patients.

METHODS

Data from seven National Health and Nutrition Examination Survey (NHANES) cycles (2005-2018) were analyzed. Kaplan-Meier survival curves and multivariate Cox proportional hazards models were used to assess the association between SDoH and mortality outcomes, including all-cause and cause-specific mortality. The sensitive analyses were performed to check the robustness of the main findings. Nonlinear relationships were explored using restricted cubic spline (RCS) analysis, offering greater flexibility than traditional linear models. Subgroup analyses further assessed the consistency and robustness of findings across different demographic and clinical factors, enhancing the depth and reliability of the results.

RESULTS

Among 1,551 COPD participants, 506 deaths occurred, including 114 from cardio-cerebrovascular diseases and 130 from cancer. Higher SDoH scores were inversely associated with survival outcomes. After adjusting for confounders, individuals with higher SDoH scores had increased risks of all-cause mortality (hazard ratio [HR] = 1.199, 95% confidence intervals [CI]:1.136, 1.264), cancer mortality (HR = 1.236, 95% CI: 1.100, 1.388), and cardio-cerebrovascular mortality (HR = 1.143, 95% CI: 1.022,1.277) compared to those with lower SDoH scores. Sensitivity analyses confirmed the positive correlations between SDoH and mortality in the COPD population. Kaplan-Meier analyses also revealed worse survival outcomes for participants with higher SDoH scores. The agreement between survival analyses and statistical modeling underscores the predictive value of SDoH in this population.

CONCLUSION

The results of our study indicate a notable positive correlation between SDoH score and the likelihood of mortality from all causes and specific causes in patients with COPD.

Predictive Value of CCQ and its Subdomains for Hospitalized Exacerbations in Chronic Obstructive Pulmonary Disease: A 3-Year Observational Prospective Study

BACKGROUND

The prediction capacity of the Clinical COPD Questionnaire (CCQ) and its functional, symptom, and mental subdomain for COPD hospitalized exacerbation were rarely studied.

OBJECTIVE

To examine the prognostic capacity of the total CCQ and its three subdomains for 3-year COPD hospitalized exacerbations.

METHODS

We analyzed the predictive ability of total CCQ score and its subdomains for hospitalized exacerbations in an observational cohort of 987 subjects with stable COPD from the RealDTC, an ongoing multicenter prospective study. Hospitalized exacerbations were prospectively collected every 6 month for a maximum of 3 years.

RESULTS

The total CCQ and its functional and symptom domain, but not the mental domain, were significantly associated with 3-year hospitalized exacerbations by multivariate Cox regression analysis. The predictive capacity of functional domain was similar to that of the total CCQ, but significantly stronger than the symptom and mental domain by ROC analysis (P < 0.05). ROC curves also showed that the AUC of exacerbation history combined with CCQ functional domain was larger than that of exacerbation history alone (P < 0.0001). Additionally, the predictive value of multivariable models that contains CCQ functional domain was significantly better than the corresponding model without CCQ functional domain (P < 0.05).

CONCLUSIONS

The total CCQ and its functional and symptom domain were independent risk factors of 3-year hospitalized exacerbations. The prognostic capacity of the functional domain was similar to that of total CCQ, and was significantly stronger than the symptom and mental domain. The CCQ functional domain was able to increase the predictive power of exacerbation history and other multivariable prediction models, indicating it may have an important role in the multivariable prediction tool for hospitalized exacerbation, and its combination with other clinical variables might be used as a low-cost approach for assessments of the disease severity and severe exacerbation in COPD patients in the future.

The impact of comprehensive public hospital reform on economic burden of inpatients with chronic obstructive pulmonary disease: evidence from a pilot city in western China

BACKGROUND

The Chinese government launched a comprehensive reform of public hospitals, including a zero-markup drug policy (ZMDP) and adjustments to the price compensation mechanism for medical services. We aimed to assess the impact of the reform on economic burden for chronic obstructive pulmonary disease (COPD) inpatients.

RESEARCH DESIGN AND METHODS

Health care institutions were selected using judgmental sampling. Structural variation analysis was conducted to assess changes in the cost structure. An interrupted time series analysis was used to evaluate level and trend changes in medical costs.

RESULTS

After the reform, the total cost, western medicine cost, and traditional Chinese medicine cost per visit decreased significantly, with monthly downward trends (p < 0.05). The proportion of western medicine cost decreased by 5.59%, but remained the main composition (31.78%). The health insurance payments, out-of-pocket (OOP) cost per visit, and OOP cost proportion decreased significantly (p < 0.05). The health insurance payments per visit showed a monthly downward trend (p < 0.001), and the decline in OOP cost per visit extended (p = 0.003).

CONCLUSIONS

The reform reduced the economic burden of COPD inpatients, optimized the cost structure and improved the efficiency of health insurance utilization. However, the short-term substitution effect of medical services on medicines weakened the cost-reduction effect.

Impact of intensive health education on influenza vaccination and acute exacerbations in outpatients with chronic obstructive pulmonary disease: a real-world study

Background

The influenza vaccination rate of chronic obstructive pulmonary disease (COPD) patients in China was very low. In this study, we aimed to evaluate the effect of clinician-led intensive health education on influenza vaccination in outpatients with COPD and the effect of influenza vaccination on the risk of acute exacerbations in the real world.

Methods

Participants were from the Real World Research of Diagnosis and Treatment of COPD study, a real-world prospective cohort study. COPD patients were included from December 2016 to April 2023 and followed up for one year. In January 2022, clinicians began strengthening health education for outpatients with COPD. We identified patients visiting the clinic from January 2022 to April 2023 as the intensive health education group and those visiting from December 2016 to December 2021 as the control group. We analysed factors associated with influenza vaccination and the effect of influenza vaccine on acute exacerbations by multivariate analysis.

Results

7834 patients were included. Compared with the control group, the intensive health education group had a higher rate of influenza vaccination (1.6% vs. 12.2%, P < 0.01). Smoking cessation, high school education or above, influenza vaccination in the past year and intensive health education were independently associated with influenza vaccination. Influenza vaccination reduced the incidence of future acute exacerbations (adjusted odds ratio (aOR) = 0.48; 95% confidence interval (CI) = 0.33-0.68, P < 0.01), frequent acute exacerbations (aOR = 0.47; 95% CI = 0.27-0.82, P = 0.01), and severe acute exacerbation (aOR = 0.38; 95% CI = 0.23-0.63, P < 0.01) in COPD patients.

Conclusions

Influenza vaccination reduced the risk of future acute exacerbations in patients with COPD. Clinician-led intensive health education can improve the influenza vaccination of outpatients with COPD, and clinicians and policymakers should pay attention to and apply this method.

The treatment responses among different inhalation therapies for GOLD group E patients with chronic obstructive pulmonary disease

Background

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2023 revised the combined chronic obstructive pulmonary disease (COPD) assessment, merging groups C and D into group E, and revised the initial inhalation therapy recommendation. We aimed to evaluate the treatment responses among different inhalation therapies in GOLD group E patients stratified by the COPD assessment test (CAT) scores and forced expiratory volume in one-second percentage of predicted (FEV1%pred).

Methods

In this retrospective cohort study, we included patients with COPD registered in the Real World Research of Diagnosis and Treatment of COPD (RealDTC) study between January 2017 and June 2023. According to the GOLD 2023 report, we enrolled patients assigned to GOLD group E based on exacerbations in the past year (≥2 exacerbations or ≥1 hospitalisation) in this study. We classified them into the FEV1%pred <50% and FEV1%pred ≥50% groups, or CAT<10 and CAT≥10 groups. Subsequently, we divided all groups into four subgroups: long-acting muscarinic antagonist (LAMA), long-acting β2-agonist (LABA) + inhaled corticosteroid (ICS), LABA + LAMA, and LABA + LAMA + ICS. All patients finished one year of follow-up, during which we collected data on exacerbations, frequent exacerbations, hospitalisations, and all-cause mortality. We defined frequent exacerbations as ≥2 exacerbations per year.

Results

We enrolled a total of 3173 patients in this study. During one year of follow-up, there were no significant differences in exacerbations, frequent exacerbations, hospitalisations, and all-cause mortality among LAMA, LABA + LAMA, LABA + ICS, and LABA + LAMA + ICS in the FEV1%pred ≥50% and CAT<10 groups. However, the patients treated with LABA + LAMA or LABA + LAMA + ICS had a lower incidence of exacerbations and frequent exacerbations compared with the patients treated with LAMA or LABA + ICS in the FEV1%pred <50% and CAT≥10 groups (P < 0.05).

Conclusions

Patients with COPD in GOLD group E should be further stratified to determine the appropriate initial inhalation therapy. This approach may provide more precise treatment for GOLD group E patients.

The associations between modifiable risk factors and constipation: a comprehensive mendelian randomization study

OBJECTIVE

Early identification of modifiable risk factors is crucial for the prevention of constipation. This study systematically investigated the relationship between genetically predicted modifiable risk factors and constipation.

METHODS

The inverse variance weighting (IVW) method was employed as the primary analytical approach. For similar exposure indicators, the multivariate Mendelian randomization (MVMR) method was used to adjust for potential biases in univariate MR analysis. The robustness of the results was further evaluated using the MR-Egger intercept test, Cochran's Q test, and leave-one-out analysis. Bonferroni correction was applied to reduce the false positive rate in the results.

RESULTS

The IVW analysis indicated a significant causal association between genetically predicted gastroesophageal reflux disease [OR (95% CI) = 1.192 (1.079-1.315), P = 0.0005], atorvastatin use [OR (95% CI) = 16.995 (3.327-86.816), P = 0.0007], and constipation. Additionally, there was a potential causal association between education level [OR (95% CI) = 0.859 (0.767-0.964), P = 0.009], major depressive disorder [OR (95% CI) = 1.206 (1.041-1.399), P = 0.013], hypothyroidism [OR (95% CI) = 2.299 (1.327-3.985), P = 0.003], and aspirin use [OR (95% CI) = 4.872 (1.174-20.221), P = 0.029] with constipation. No causal associations were found for the other included indicators. Sensitivity analysis demonstrated the absence of evidence for heterogeneity and pleiotropy in any positive results.

CONCLUSION

This study identified several risk factors that could be targeted for the prevention of constipation, offering valuable insights for public health policies.

Impact of exacerbation history on future risk and treatment outcomes in chronic obstructive pulmonary disease patients: A prospective cohort study based on Global Initiative for Chronic Obstructive Lung Disease (GOLD) A and B classifications

Background

In this study, we aimed to explore the impact of exacerbation history on future exacerbation and mortality with different inhaled drugs in chronic obstructive pulmonary disease (COPD) patients based on a Global Initiative Chronic Obstructive Lung Disease (GOLD) A and B classifications.

Methods

This observational study was based on the cohort study Real World Research of Diagnosis and Treatment of COPD (RealDTC). We collected data from COPD patients in China from 1 July 2017 to 31 December 2022. Patients were followed up until December 2023 or death. Further, we separated GOLD A and B patients into GOLD A0 and B0, who had no exacerbation during the previous year, and GOLD A1 and B1, who had only one exacerbation during the previous year. Study outcomes included moderate-to-severe exacerbation, hospitalisation, frequent exacerbation in the first year and all-cause mortality during total follow-up.

Results

Of the 8318 eligible patients, GOLD E group of patients suffered from a greater risk of exacerbation in the first year and death than patients in the GOLD A and B groups. GOLD A1 group had a higher risk of moderate-to-severe exacerbation (hazard ratio (HR) = 2.087; 95% confidence interval (CI) = 1.419-3.068), hospitalisation (HR = 1.704; 95% CI = 1.010-2.705) and frequent exacerbation (HR = 1.983; 95% CI = 1.046-3.709) compared to GOLD A0. GOLD B1 group had a risk of moderate-to-severe exacerbation (HR = 1.321; 95% CI = 1.105-1.679) and mortality (HR = 1.362; 95% CI = 1.026-1.963) that exceeded the risk in GOLD B0 group. The treatment outcome of different inhaled drugs had no statistical differences in GOLD A0 group. In GOLD A1 group, only inhaled corticosteroids (ICS), in addition to long-acting β-2 agonist (LABA) and long-acting muscarinic antagonist (LAMA), reduced the risk of moderate-to-severe exacerbation in the first year compared to only LAMA. As for the GOLD B0 group, LABA and LAMA decreased the odds of moderate-to-severe exacerbation, hospitalisation, frequent exacerbation and mortality compared to only LAMA. ICS, LABA, and LAMA in GOLD B0 also down-regulated the risk of frequent exacerbation, compared to only LAMA. In addition, GOLD B1 patients treated with LABA and LAMA or ICS, LABA, and LAMA had a lower risk of moderate-to-severe exacerbation and hospitalisation. Meanwhile, ICS, LABA, and LAMA also reduced the risk of frequent exacerbation and mortality, compared to only LAMA in the multivariate Cox analysis.

Conclusions

Compared to the GOLD A or B group without exacerbation history, GOLD A patients with exacerbation history had a higher risk of future exacerbation, and GOLD B patients with exacerbation history had a higher risk of future exacerbation and mortality and benefited more from triple inhaler therapy.

Impact of Income-to-Poverty Ratio on Long-Term Mortality of Persons with Chronic Liver Disease in the USA, 1999-2018

INTRODUCTION

Chronic liver disease (CLD) is associated with increased morbidity and mortality. Understanding health disparities can inform appropriate interventions. We aimed to study mortality outcomes of those with CLD by the income level (income-to-poverty ratio <5 as lower income and ≥5 as higher income).

METHODS

In this retrospective cohort study, we analyzed data of adults from the National Health and Nutrition Examination Survey, 1999-2018. CLD included viral hepatitis, nonalcoholic fatty liver disease (NAFLD), and alcohol-associated liver disease (ALD).

RESULTS

We analyzed 59,204 adults: 47,224 without CLD and 11,980 with CLD. The CLD group was older, more likely male, racial/ethnic minority groups or foreign-born, and had lower educational and income levels (p < 0.001). Most (80.02%) CLD participants did not have college degrees and had lower income (79.18%). Among CLD participants, similar differences were observed between lower and higher income groups. Lower income participants with CLD had significantly higher 10-year cumulative mortality compared to higher income CLD participants (15.26 vs. 8.00%, p < 0.001), with consistent findings in viral hepatitis and NAFLD subgroups (p < 0.001) but not ALD (p = 0.71). Adjusting for age, sex, race, birthplace, lower income CLD participants were 2.01 (hazard ratio [HR]: 2.01; 95% CI: 1.79-2.26) times more likely to die overall and in viral hepatitis (HR: 2.05; 95% CI: 1.31-3.24) and NAFLD subgroups (HR: 2.32; 95% CI: 1.69-3.18) but not ALD (HR: 1.17; 95% CI: 0.55-2.51).

CONCLUSION

Lower income, foreign-born, and racial/ethnic minority groups were disproportionately represented among those with CLD, with lower income and CLD individuals having double the mortality risk compared to their higher income counterparts. Interventions should be culturally appropriate and address socioeconomic barriers.

Development and validation of a nomogram model for mortality prediction in stable chronic obstructive pulmonary disease patients: A prospective observational study in the RealDTC cohort

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death worldwide. There is no nomogram model available for mortality prediction of stable COPD. We intended to develop and validate a nomogram model to predict mortality risk in stable COPD patients for personalised prognostic assessment.

METHODS

A prospective observational study was made of COPD outpatients registered in the RealDTC study between December 2016 and December 2019. Patients were randomly assigned to the training cohort and validation cohort in a ratio of 7:3. We used Lasso regression to screen predicted variables. Further, we evaluated the prognostic performance using the area under the time-dependent receiver operating characteristic curve (AUC) and calibration curve. We used the AUC, concordance index, and decision curve analysis to evaluate the net benefits and utility of the nomogram compared with three earlier prediction models.

RESULTS

Of 2499 patients, the median follow-up was 38 months. The characteristics of the patients between the training cohort (n = 1743) and the validation cohort (n = 756) were similar. ABEODS nomogram model, combining age, body mass index, educational level, airflow obstruction, dyspnoea, and severe exacerbation in the first year, was constructed to predict mortality in stable COPD patients. In the integrative analysis of training and validation cohorts of the nomogram model, the three-year mortality prediction achieved AUC = 0.84; 95% confidence interval (CI) = 0.81, 0.88 and AUC = 0.80; 95% CI = 0.74, 0.86, respectively. The ABEODS nomogram model preserved excellent calibration in both the training cohort and validation cohort. The time-dependent AUC, concordance index, and net benefit of the nomogram model were higher than those of BODEx, updated ADO, and DOSE, respectively.

CONCLUSIONS

We developed and validated a prognostic nomogram model that accurately predicts mortality across the COPD severity spectrum. The proposed ABEODS nomogram model performed better than earlier models, including BODEx, updated ADO, and DOSE in Chinese patients with COPD.

REGISTRATION

ChiCTR-POC-17010431.