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Smirnova N, Lange AV, Glickman A, Desanto K, McDermott CL, Sullivan DR, Bekelman DB, Kavalieratos D. Criteria for Enrollment of Patients With COPD in Palliative Care Trials: A Systematic Review. J Pain Symptom Manage 2024; 67:e891-e905. [PMID: 38280439 PMCID: PMC11088983 DOI: 10.1016/j.jpainsymman.2024.01.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 01/11/2024] [Accepted: 01/13/2024] [Indexed: 01/29/2024]
Abstract
CONTEXT Use of palliative care interventions in chronic obstructive pulmonary disease (COPD) has increased in recent years and inclusion criteria used to identify patients with COPD appropriate for palliative care vary widely. We evaluated the inclusion criteria to identify ways to improve enrollment opportunities for patients with COPD. OBJECTIVES To determine inclusion criteria used to select patients with COPD for palliative care trials. METHODS A systematic review was conducted to determine criteria used to select patients with COPD for palliative care randomized controlled trials. A narrative synthesis was conducted for all trials. RESULTS Inclusion criteria were highly heterogeneous. Most studies (n = 11, 79%) used a combination of criteria to identify patients with COPD. Commonly used criteria included hospitalization for an acute exacerbation of COPD (n = 8, 57%), home supplemental oxygen use (n = 8, 57%), and spirometry values confirming COPD (n = 6, 43%). Three studies (21.4%) used Modified Medical Research Council score and two studies (21%) used physician prognosis or a performance scale. CONCLUSION The most common criteria, a hospitalization for acute exacerbation of COPD or supplemental oxygen use at home, both have the benefit of selecting patients who have a higher symptom burden or higher healthcare utilization who might therefore benefit more from palliative care. By describing the landscape and variability of previously used inclusion criteria, this article serves as a resource for clinicians and researchers. Developing a consistent set of inclusion criteria in the future would help generate generalizable results that can be translated into clinical practice to improve the lives of patients with COPD. PROSPERO REGISTRATION NUMBER CRD42022306752.
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Affiliation(s)
- Natalia Smirnova
- Division of Pulmonary, Allergy and Critical Care Medicine (N.S.), Emory University School of Medicine, Atlanta, Georgia, USA
| | - Allison V Lange
- Division of Pulmonary Sciences and Critical Care Medicine (A.V.L.), University of Colorado School of Medicine, Aurora, Colorado, USA.
| | - Amanda Glickman
- Division of General Internal Medicine (A.G., D.B.B.), University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Kristen Desanto
- Strauss Health Sciences Library (K.D.), University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Cara L McDermott
- Division of Geriatrics (C.L.M.), Duke University School of Medicine, Durham, North Carolina, USA
| | - Donald R Sullivan
- Division of Pulmonary, Allergy and Critical Care Medicine (D.R.S.), Oregon Health and Science University, Portland, Oregon, USA; Center to Improve Veteran Involvement in their Care (CIVIC) (D.R.S.), VA Portland Health Care System, Portland, Oregon, USA; Knight Cancer Institute (D.R.S.), Oregon Health and Science University, Portland, Oregon, USA
| | - David B Bekelman
- Division of General Internal Medicine (A.G., D.B.B.), University of Colorado School of Medicine, Aurora, Colorado, USA; Department of Medicine, Eastern Colorado Health Care System, Department of Veterans Affairs (D.B.B.), Denver, Aurora, Colorado, USA
| | - Dio Kavalieratos
- Division of Palliative Medicine (D.K.), Emory University School of Medicine, Atlanta, Georgia, USA; Rollins School of Public Health (D.K.), Emory University, Atlanta, Georgia, USA
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Lin SJ, Liao XM, Chen NY, Chang YC, Cheng CL. Beta-blockers reduce severe exacerbation in patients with mild chronic obstructive pulmonary disease with atrial fibrillation: a population-based cohort study. BMJ Open Respir Res 2023; 10:e001854. [PMID: 37989489 PMCID: PMC10660430 DOI: 10.1136/bmjresp-2023-001854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 10/27/2023] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Beta-blockers (BBs) decrease mortality and acute exacerbation (AE) rates in patients with chronic obstructive pulmonary disease (COPD) and cardiovascular disease; however, information on their effects in patients with COPD and atrial fibrillation (AF) is limited. We aimed to assess the AE risk in patients with different severities of COPD and AF receiving BBs compared with that in patients receiving calcium channel blockers (CCBs). METHODS This retrospective cohort study used data from the Taiwan National Health Insurance Database from 2009 to 2018. Outcomes included AE-related emergency room visits and hospitalisation. HRs and 95% CIs were estimated using the Cox proportional hazards model. COPD severity was classified as mild or severe based on exacerbation history. Sensitivity analyses included treatment and subgroup analyses, and competing risk adjustment. RESULTS After propensity score matching, 4486 pairs of BB and CCB users from 13 462 eligible patients were included. The exacerbation risk for BB users was lower (HR 0.80; 95% CI 0.72 to 0.89) than that of CCB users. After stratification, BB benefits persisted in the mild COPD group (HR 0.75; 95% CI 0.66 to 0.85), unlike the severe COPD group (HR 0.95; 95% CI 0.75 to 1.20). The results of the subgroup analysis showed consistent protective effects even in patients without heart failure or myocardial infarction (adjusted HR 0.82; 95% CI 0.71 to 0.94). CONCLUSION We found that BB use in patients with mild COPD and AF was associated with a lower exacerbation risk than CCB use, and that close monitoring of BB use in patients with severe COPD and AF is warranted.
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Affiliation(s)
- Shan-Ju Lin
- School of Pharmacy and Institute of Clinical Pharmacy and Pharmaceutical Sciences, National Cheng Kung University, Tainan, Taiwan
| | - Xin-Min Liao
- Department of Internal Medicine, National Cheng Kung University, Tainan, Taiwan
- Institute of clinical medicine, National Cheng Kung University, Tainan, Taiwan
| | - Nai-Yu Chen
- School of Pharmacy and Institute of Clinical Pharmacy and Pharmaceutical Sciences, National Cheng Kung University, Tainan, Taiwan
- Department of Pharmacy, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Yu-Ching Chang
- School of Pharmacy and Institute of Clinical Pharmacy and Pharmaceutical Sciences, National Cheng Kung University, Tainan, Taiwan
- Health Outcome Research Center, National Cheng Kung University, Tainan, Taiwan
| | - Ching-Lan Cheng
- School of Pharmacy and Institute of Clinical Pharmacy and Pharmaceutical Sciences, National Cheng Kung University, Tainan, Taiwan
- Health Outcome Research Center, National Cheng Kung University, Tainan, Taiwan
- Department of Pharmacy, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Feldman WB, Kesselheim AS, Avorn J, Russo M, Wang SV. Comparative Effectiveness and Safety of Generic Versus Brand-Name Fluticasone-Salmeterol to Treat Chronic Obstructive Pulmonary Disease. Ann Intern Med 2023; 176:1047-1056. [PMID: 37549393 DOI: 10.7326/m23-0615] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/09/2023] Open
Abstract
BACKGROUND In 2019, the U.S. Food and Drug Administration (FDA) approved the first generic maintenance inhaler for asthma and chronic obstructive pulmonary disease (COPD). The inhaler, Wixela Inhub (fluticasone-salmeterol; Viatris), is a substitutable version of the dry powder inhaler Advair Diskus (fluticasone-salmeterol; GlaxoSmithKline). When approving complex generic products like inhalers, the FDA applies a special "weight-of-evidence" approach. In this case, manufacturers were required to perform a randomized controlled trial in patients with asthma but not COPD, although the product received approval for both indications. OBJECTIVE To compare the effectiveness and safety of generic (Wixela Inhub) and brand-name (Advair Diskus) fluticasone-salmeterol among patients with COPD treated in routine care. DESIGN A 1:1 propensity score-matched cohort study. SETTING A large, longitudinal health care database. PATIENTS Adults older than 40 years with a diagnosis of COPD. MEASUREMENTS Incidence of first moderate or severe COPD exacerbation (effectiveness outcome) and incidence of first pneumonia hospitalization (safety outcome) in the 365 days after cohort entry. RESULTS Among 45 369 patients (27 305 Advair Diskus users and 18 064 Wixela Inhub users), 10 012 matched pairs were identified for the primary analysis. Compared with Advair Diskus use, Wixela Inhub use was associated with a nearly identical incidence of first moderate or severe COPD exacerbation (hazard ratio [HR], 0.97 [95% CI, 0.90 to 1.04]) and first pneumonia hospitalization (HR, 0.99 [CI, 0.86 to 1.15]). LIMITATIONS Follow-up times were short, reflecting real-world clinical practice. The possibility of residual confounding cannot be completely excluded. CONCLUSION Use of generic and brand-name fluticasone-salmeterol was associated with similar outcomes among patients with COPD treated in routine practice. PRIMARY FUNDING SOURCE National Heart, Lung, and Blood Institute.
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Affiliation(s)
- William B Feldman
- Program on Regulation, Therapeutics, and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts (W.B.F.)
| | - Aaron S Kesselheim
- Program on Regulation, Therapeutics, and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts (A.S.K., J.A.)
| | - Jerry Avorn
- Program on Regulation, Therapeutics, and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts (A.S.K., J.A.)
| | - Massimiliano Russo
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts (M.R., S.V.W.)
| | - Shirley V Wang
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts (M.R., S.V.W.)
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Duan KI, Donovan LM, Spece LJ, Feemster LC, Bryant AD, Plumley R, Collins MP, Au DH. Trends and Rural-Urban Differences in the Initial Prescription of Low-Value Inhaled Corticosteroids among U.S. Veterans with Chronic Obstructive Pulmonary Disease. Ann Am Thorac Soc 2023; 20:668-676. [PMID: 36867427 PMCID: PMC10174122 DOI: 10.1513/annalsats.202205-458oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 02/27/2023] [Indexed: 03/03/2023] Open
Abstract
Rationale: Guidelines recommend inhaled corticosteroids (ICS) for patients with chronic obstructive pulmonary disease (COPD) and select indications, including asthma history, high exacerbation risk, or high serum eosinophils. ICS are commonly prescribed outside of these indications, despite evidence of harm. We defined a "low-value" ICS prescription as the receipt of an ICS without evidence of a guideline-recommended indication. ICS prescription patterns are not well characterized and could inform health system interventions to reduce low-value practices. Objectives: To evaluate the national trends in initial low-value ICS prescriptions in the U.S. Department of Veterans Affairs and to determine whether rural-urban differences in low-value ICS prescribing exist. Methods: We performed a cross-sectional study between January 4, 2010, and December 31, 2018, identifying veterans with COPD who were new users of inhaler therapy. We defined low-value ICS as prescriptions in patients with 1) no asthma, 2) low risk of future exacerbation (Global Initiative for Chronic Obstructive Lung Disease group A or B), and 3) serum eosinophils <300 cells/μl. We performed multivariable logistic regression to evaluate trends in low-value ICS prescription over time, adjusting for potential confounders. We performed fixed effects logistic regression to assess rural-urban prescribing patterns. Results: We identified a total of 131,009 veterans with COPD starting inhaler therapy, 57,472 (44%) of whom were prescribed low-value ICS as initial therapy. From 2010 to 2018, the probability of receiving low-value ICS as initial therapy increased by 0.42 percentage points per year (95% confidence interval, 0.31-0.53). Compared with urban residence, rural residence was associated with a 2.5-percentage-point (95% confidence interval, 1.9-3.1) higher probability of receiving low-value ICS as initial therapy. Conclusions: The prescription of low-value ICS as initial therapy is common and increasing slightly over time for both rural and urban veterans. Given the widespread and persistent nature of low-value ICS prescribing, health system leaders should consider system-wide approaches to address this low-value prescribing practice.
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Affiliation(s)
- Kevin I. Duan
- Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington; and
| | - Lucas M. Donovan
- Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington; and
| | - Laura J. Spece
- Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington; and
| | - Laura C. Feemster
- Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington; and
| | | | - Robert Plumley
- Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Margaret P. Collins
- Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - David H. Au
- Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington; and
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Lange AV, Mehta AB, Bekelman DB. How Important is Spirometry for Identifying Patients with COPD Appropriate for Palliative Care? J Pain Symptom Manage 2023; 65:e181-e187. [PMID: 36423798 PMCID: PMC10998735 DOI: 10.1016/j.jpainsymman.2022.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 11/10/2022] [Accepted: 11/14/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Providing palliative care to patients with chronic obstructive pulmonary disease (COPD) is a priority. Spirometry demonstrating airflow limitation is a diagnostic test for COPD and a common inclusion criterion for palliative care research. However, requiring spirometry with airflow limitation may exclude appropriate patients unable to complete spirometry, or patients with preserved-ratio impaired spirometry and symptoms or imaging consistent with COPD. MEASURES To determine differences in quality of life (QOL) and symptoms between patients with COPD identified based on International Classification of Diseases (ICD) codes and spirometry with airflow limitation compared to ICD codes only. INTERVENTION Patients with COPD enrolled in a palliative care trial were included. Patients were at high risk of hospitalization and death and reported poor QOL. Baseline measures of QOL (Functional Assessment of Cancer Therapy-General (FACT-G), the Clinical COPD Questionnaire, and Quality of Life at the End of Life), and symptoms (Patient Health Questionnaire-8, Generalized Anxiety Disorder-7, fatigue, Insomnia Severity Index) were compared. OUTCOMES Two hundred eight patients with COPD were predominantly male, White, and average age was 68.4. Between patients with ICD codes and spirometry with airflow limitation compared to patients with ICD codes only, there were no significant differences in FACT-G (59.0 vs. 55.0, P = 0.33), other measures of QOL, or symptoms between groups. CONCLUSION These results imply that spirometry may not need to be a requirement for inclusion into palliative care research or clinical care for patients with poor quality of life and at high risk for adverse outcomes.
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Affiliation(s)
- Allison V Lange
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine (A.L., A.M.); University of Colorado Anschutz Medical Campus; Aurora, Colorado.
| | - Anuj B Mehta
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine (A.L., A.M.); University of Colorado Anschutz Medical Campus; Aurora, Colorado; Division of Pulmonary and Critical Care Medicine, Department of Medicine (A.M.), Denver Health and Hospital Authority; Denver, Colorado
| | - David B Bekelman
- Medical Service (D.B.), Rocky Mountain Regional Veterans Affairs Medical Center; Aurora, Colorado; Denver-Seattle Center of Innovation (D.B.); Rocky Mountain Regional Veterans Affairs Medical Center; Aurora, Colorado; Division of General Internal Medicine, Department of Medicine (D.B.); University of Colorado Anschutz Medical Campus; Aurora, Colorado
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Osundolire S, Goldberg RJ, Lapane KL. Descriptive Epidemiology of Chronic Obstructive Pulmonary Disease in US Nursing Home Residents With Heart Failure. Curr Probl Cardiol 2023; 48:101484. [PMID: 36343840 PMCID: PMC9849011 DOI: 10.1016/j.cpcardiol.2022.101484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 10/31/2022] [Indexed: 11/06/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is highly prevalent in older adults with heart failure and heart failure is highly prevalent in older adults with COPD. Information is presently lacking about the extent to which COPD and heart failure co-occur among nursing home residents. The objective of this study was to describe the epidemiology of, and factors associated with, COPD among nursing home residents with heart failure. This cross-sectional study included 97,495 long-term stay nursing home residents with heart failure in 2018. The Minimum Data Set 3.0 (MDS) provided information on sociodemographic characteristics, comorbid conditions, and activities of daily living. Heart failure and COPD were defined based on notes at admission, hospitalizations, progress notes, and through physical examination findings. The majority of the study population were ≥75 years old (74.1%), women (67.3%), and Non-Hispanic Whites (77.4%). Nearly 1 in 5 residents had reduced ejection fraction findings, 23.1% had a preserved ejection fraction, and 53.8% of nursing home residents with heart failure had COPD. This pulmonary condition was less frequently noted in women, residents of advanced age, and racial/ethnic minorities and more frequently diagnosed in residents with comorbid conditions such as pneumonia, anxiety, obesity, diabetes mellitus, and coronary artery disease. We found a high prevalence of COPD, and identified several factors associated with COPD, in nursing home residents with heart failure. Our findings highlight challenges in the clinical management of COPD in nursing home residents with heart failure and how best to meet the care needs of this understudied population.
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Affiliation(s)
- Seun Osundolire
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA.
| | - Robert J Goldberg
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Kate L Lapane
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
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Weng SC, Lin CF, Hsu CY, Lin SY. Effect of frailty, physical performance, and chronic kidney disease on mortality in older patients with diabetes : a retrospective longitudinal cohort study. Diabetol Metab Syndr 2023; 15:7. [PMID: 36650566 PMCID: PMC9843852 DOI: 10.1186/s13098-022-00972-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 12/24/2022] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Declined renal function is associated with physical function impairment and frailty in a graded fashion. This study aimed to examine the relationship between renal function, frailty and physical performance with mortality in older patients with diabetes, while also determining their combined effects on patient outcome. METHODS A retrospective longitudinal study was conducted in elderly patients with diabetes. Kidney disease staging was based on clinical practice guidelines of the International Society of Nephrology, and chronic kiney disease (CKD) was defined as urinary albumin to creatinine ratio (UACR) > 30 mg/g, persistent reduction in estimated glomerular filtration rate (eGFR) below 60 mL/min per 1.73 m2 or both. The modified Rockwood frailty index (RFI) was composed of cumulative health deficits, and physical function was determined by handgrip strength (HGS). Additionally, a timed up and go (TUG) test was assessed at baseline. Kaplan-Meier survival and Cox proportional hazard analyses were used to analyze the association between CKD, frailty, physical function and mortality. RESULTS For the 921 enrolled patients, their mean age was 82.0 ± 6.7 years. After a median 2.92 (interquartile range [IQR] 1.06-4.43) year follow-up, the survival rate was 67.6% and 85.5% in patients with and without CKD, respectively. The mortality hazard ratio (crude HR) with CKD was 5.92 for those with an RFI higher than 0.313 (95% CI 3.44-10.18), 2.50 for a TUG time longer than 21 s (95% CI 1.22-5.13), and 2.67 for an HGS lower than 10.57 kg in females or 20.4 kg in males (95% CI 1.12-6.37). After multivariate adjustment, the mortality hazard ratio for an RFI ≥ 0.313 was 5.34 (95% CI 2.23-12.80) in CKD patients, but not in patients without CKD. In subgroup analysis, patients experiencing CKD and frailty, or physical function impairment, had the lowest survival proportion followed by only frailty/declined physical function, only CKD, without CKD, and non-frailty/non-physical impairment. CONCLUSION CKD, frailty and physical function impairment were all associated with an increased mortality risk in older patients with diabetes, while the combined effects of these 3 factors were seen on patient outcome.
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Affiliation(s)
- Shuo-Chun Weng
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
- Research Center for Geriatrics and Gerontology, College of Medicine, National Chung Hsing University, Taichung, Taiwan
- Center for Geriatrics and Gerontology, Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Institute of Clinical Medicine, School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Cheng-Fu Lin
- Research Center for Geriatrics and Gerontology, College of Medicine, National Chung Hsing University, Taichung, Taiwan
- Center for Geriatrics and Gerontology, Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Institute of Clinical Medicine, School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Occupational Medicine, Department of Emergency, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chiann-Yi Hsu
- Biostatistics Task Force of Taichung Veterans General Hospital, Taichung, Taiwan
| | - Shih-Yi Lin
- Research Center for Geriatrics and Gerontology, College of Medicine, National Chung Hsing University, Taichung, Taiwan.
- Institute of Clinical Medicine, School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
- Center for Geriatrics and Gerontology, Division of Endocrinology and Metabolism, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.
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Myers LC, Murray R, Donato B, Liu VX, Kipnis P, Shaikh A, Franchino-Elder J. Risk of hospitalization in a sample of COVID-19 patients with and without chronic obstructive pulmonary disease. Respir Med 2023; 206:107064. [PMID: 36459955 PMCID: PMC9700393 DOI: 10.1016/j.rmed.2022.107064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 11/21/2022] [Accepted: 11/23/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND OBJECTIVE Patients with chronic obstructive pulmonary disease (COPD) may have worse coronavirus disease-2019 (COVID-19)-related outcomes. We compared COVID-19 hospitalization risk in patients with and without COPD. METHODS This retrospective cohort study included patients ≥40 years, SARS-CoV-2 positive, and with Kaiser Permanente Northern California membership ≥1 year before COVID-19 diagnosis (electronic health records and claims data). COVID-19-related hospitalization risk was assessed by sequentially adjusted logistic regression models and stratified by disease severity. Secondary outcome was death/hospice referral after COVID-19. RESULTS AND DISCUSSION Of 19,558 COVID-19 patients, 697 (3.6%) had COPD. Compared with patients without COPD, COPD patients were older (median age: 69 vs 53 years); had higher Elixhauser Comorbidity Index (5 vs 0) and more median baseline outpatient (8 vs 4), emergency department (2 vs 1), and inpatient (2 vs 1) encounters. Unadjusted analyses showed increased odds of hospitalization with COPD (odds ratio [OR]: 3.93; 95% confidence interval [CI]: 3.40-4.60). After full risk adjustment, there were no differences in odds of hospitalization (OR: 1.14, 95% CI: 0.93-1.40) or death/hospice referral (OR: 0.96, 95% CI: 0.72-1.27) between patients with and without COPD. Primary/secondary outcomes did not differ by COPD severity, except for higher odds of hospitalization in COPD patients requiring supplemental oxygen versus those without COPD (OR: 1.84, 95% CI: 1.02-3.33). CONCLUSIONS Except for hospitalization among patients using supplemental oxygen, no differences in odds of hospitalization or death/hospice referral were observed in the COVID-19 patient sample depending on whether they had COPD.
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Affiliation(s)
- Laura C. Myers
- The Permanente Medical Group, Kaiser Permanente Northern California, Oakland, CA, USA,Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA,Corresponding author. Division of Research, Kaiser Permanente Northern California Oakland, CA, 94612, USA
| | | | - Bonnie Donato
- Health Economics and Outcomes Research, Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, CT, USA
| | - Vincent X. Liu
- The Permanente Medical Group, Kaiser Permanente Northern California, Oakland, CA, USA,Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Patricia Kipnis
- The Permanente Medical Group, Kaiser Permanente Northern California, Oakland, CA, USA,Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Asif Shaikh
- Clinical Development and Medical Affairs, Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, CT, USA
| | - Jessica Franchino-Elder
- Health Economics and Outcomes Research, Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, CT, USA
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Rojas JC, Chokkara S, Zhu M, Lindenauer PK, Press VG. Care Quality for Patients with Chronic Obstructive Pulmonary Disease in the Readmission Penalty Era. Am J Respir Crit Care Med 2023; 207:29-37. [PMID: 35916652 PMCID: PMC9952855 DOI: 10.1164/rccm.202203-0496oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 08/02/2022] [Indexed: 02/03/2023] Open
Abstract
Rationale: Chronic obstructive pulmonary disease (COPD) is the fifth-leading cause of admissions and third-leading cause of readmissions among U.S. adults. Recent policies instituted financial penalties for excessive COPD readmissions. Objectives: To evaluate changes in the quality of care for patients hospitalized for COPD after implementation of the Hospital Readmissions Reduction Program (HRRP). Methods: We conducted a retrospective cohort study of patients older than 40 years of age hospitalized for COPD across 995 U.S. hospitals (Premier Healthcare Database). Measurements and Main Results: Quality of care before and after HRRP implementation was measured via adherence to recommended inpatient care treatments for acute exacerbations of COPD (recommended care, nonrecommended care, "ideal care" [all recommended and no nonrecommended care]). We included 662,842 pre-HRRP (January 2010-September 2014) and 285,508 post-HRRP (October 2014-December 2018) admissions. Recommended care increased at a rate of 0.16% per month pre-HRRP and 0.01% per month post-HRRP (P < 0.001). Nonrecommended care decreased at a rate of 0.15% per month pre-HRRP and 0.13% per month post-HRRP. Ideal care increased at a rate of 0.24% per month pre-HRRP and 0.11% per month post-HRRP (P < 0.001). Conclusions: The pre-HRRP trends toward improving care quality for inpatient COPD care slowed after HRRP implementation. This suggests that financial penalties for readmissions did not stimulate higher quality of care for patients hospitalized with COPD. It remains unclear what policies or approaches will be effective to ensure high care quality for patients hospitalized with COPD exacerbations.
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Affiliation(s)
- Juan C. Rojas
- Department of Medicine, University of Chicago, Chicago, Illinois; and
| | - Sukarn Chokkara
- Department of Medicine, University of Chicago, Chicago, Illinois; and
| | - Mengqi Zhu
- Department of Medicine, University of Chicago, Chicago, Illinois; and
| | - Peter K. Lindenauer
- Department of Healthcare Delivery and Population Sciences, University of Massachusetts Chan Medical School – Baystate, Springfield, Massachusetts
| | - Valerie G. Press
- Department of Medicine, University of Chicago, Chicago, Illinois; and
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Weng SC, Hsu CY, Wu MF, Lee WH, Lin SY. The Impact of Frailty Status on Pulmonary Function and Mortality in Older Patients with Chronic Obstructive Pulmonary Disease. J Nutr Health Aging 2023; 27:987-995. [PMID: 37997720 DOI: 10.1007/s12603-023-2017-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 10/10/2023] [Indexed: 11/25/2023]
Abstract
OBJECTIVES We aimed to evaluate the effect of frailty on lung function and disease outcomes in older adults with chronic obstructive pulmonary disease (COPD). DESIGN Retrospective observational cohort. SETTING AND PARTICIPANTS At baseline, comprehensive geriatric assessment and pulmonary function tests were extracted from the case management care system of the geriatric department of a tertiary medical center. MEASUREMENTS Frailty was assessed by the modified Rockwood frailty index. Kaplan-Meier survival and Cox proportional hazard analyses were used to analyze the primary outcome. Both the Friedman test and generalized estimating equations were used to evaluate the rate of decline in lung function. RESULTS Among 151 enrolled older patients, comprising 69 non-COPD and 82 COPD subjects, the mean age was 80.9±8.3 years. After a median follow-up of 2.87 years, the serial forced expiratory volume in 1 s/forced vital capacity (FEV1/FVC), and forced expiratory flow at 25-75% of FVC (FEF25-75%) showed significantly different slope changes between older COPD patients with and without frailty. The mortality hazard ratio (HR) was 2.53 for COPD without frailty and 3.62 for COPD with frailty, versus those without COPD. Among COPD patients, the factors most strongly associated with mortality were timed up-and-go, activities of daily living (ADLs), instrumental ADLs, FEV1/FVC, and serum HCO3-. After adjustment for potential confounders, ADLs and FEV1/FVC remained independent mortality predictors. CONCLUSION Among older patients with COPD, frailty was common and associated with pulmonary function decline, and mortality risk was higher in frail than in non-frail subjects.
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Affiliation(s)
- S-C Weng
- Dr. Shih-Yi Lin, Center for Geriatrics and Gerontology, Division of Endocrinology and Metabolism, Department of Internal Medicine, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, Taichung, Taiwan 407219. Fax: +886-4-23759378, Tel: +886-4-23592525-3208, E-mail address:
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11
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Pradhan R, Lu S, Yin H, Yu OHY, Ernst P, Suissa S, Azoulay L. Novel antihyperglycaemic drugs and prevention of chronic obstructive pulmonary disease exacerbations among patients with type 2 diabetes: population based cohort study. BMJ 2022; 379:e071380. [PMID: 36318979 PMCID: PMC9623550 DOI: 10.1136/bmj-2022-071380] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To determine whether the use of glucagon-like peptide 1 (GLP-1) receptor agonists, dipeptidyl peptidase 4 (DPP-4) inhibitors, and sodium-glucose co-transporter-2 (SGLT-2) inhibitors, separately, is associated with a decreased risk of exacerbations of chronic obstructive pulmonary disease among patients with chronic obstructive pulmonary disease and type 2 diabetes. DESIGN Population based cohort study using an active comparator, new user design. SETTING The United Kingdom Clinical Practice Research Datalink linked with the Hospital Episode Statistics Admitted Patient Care and Office for National Statistics databases. PARTICIPANTS Three active comparator, new user cohorts of patients starting the study drugs (GLP-1 receptor agonists, DPP-4 inhibitors, or SGLT-2 inhibitors) or sulfonylureas with a history of chronic obstructive pulmonary disease. The first cohort included 1252 patients starting GLP-1 receptor agonists and 14 259 starting sulfonylureas, the second cohort included 8731 patients starting DPP-4 inhibitors and 18 204 starting sulfonylureas, and the third cohort included 2956 patients starting SGLT-2 inhibitors and 10 841 starting sulfonylureas. MAIN OUTCOME MEASURES Cox proportional hazards models with propensity score fine stratification weighting were fitted to estimate hazard ratios and 95% confidence intervals of severe exacerbation of chronic obstructive pulmonary disease (defined as hospital admission for chronic obstructive pulmonary disease), separately for GLP-1 receptor agonists, DPP-4 inhibitors, and SGLT-2 inhibitors. Whether these drugs were associated with a decreased risk of moderate exacerbation (defined as a co-prescription of an oral corticosteroid and an antibiotic along with an outpatient diagnosis of acute chronic obstructive pulmonary disease exacerbation on the same day) was also assessed. RESULTS Compared with sulfonylureas, GLP-1 receptor agonists were associated with a 30% decreased risk of severe exacerbation (3.5 v 5.0 events per 100 person years; hazard ratio 0.70, 95% confidence interval 0.49 to 0.99) and moderate exacerbation (0.63, 0.43 to 0.94). DPP-4 inhibitors were associated with a modestly decreased incidence of severe exacerbation (4.6 v. 5.1 events per 100 person years; hazard ratio 0.91, 0.82 to 1.02) and moderate exacerbation (0.93, 0.82 to 1.07), with confidence intervals including the null value. Finally, SGLT-2 inhibitors were associated with a 38% decreased risk of severe exacerbation (2.4 v 3.9 events per 100 person years; hazard ratio 0.62, 0.48 to 0.81) but not moderate exacerbation (1.02, 0.83 to 1.27). CONCLUSIONS In this population based study, GLP-1 receptor agonists and SGLT-2 inhibitors were associated with a reduced risk of severe exacerbations compared with sulfonylureas in patients with chronic obstructive pulmonary disease and type 2 diabetes. DPP-4 inhibitors were not clearly associated with a decreased risk of chronic obstructive pulmonary disease exacerbations.
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Affiliation(s)
- Richeek Pradhan
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, QC, Canada
| | - Sally Lu
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, QC, Canada
| | - Hui Yin
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, QC, Canada
| | - Oriana H Y Yu
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, QC, Canada
- Division of Endocrinology, Jewish General Hospital, Montreal, QC, Canada
| | - Pierre Ernst
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, QC, Canada
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Samy Suissa
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, QC, Canada
| | - Laurent Azoulay
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, QC, Canada
- Gerald Bronfman Department of Oncology, McGill University, Montreal, QC, Canada
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12
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Bonomo M, Hermsen MG, Kaskovich S, Hemmrich MJ, Rojas JC, Carey KA, Venable LR, Churpek MM, Press VG. Using Machine Learning to Predict Likelihood and Cause of Readmission After Hospitalization for Chronic Obstructive Pulmonary Disease Exacerbation. Int J Chron Obstruct Pulmon Dis 2022; 17:2701-2709. [PMID: 36299799 PMCID: PMC9590342 DOI: 10.2147/copd.s379700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 10/05/2022] [Indexed: 11/05/2022] Open
Abstract
Background Chronic obstructive pulmonary disease (COPD) is a leading cause of hospital readmissions. Few existing tools use electronic health record (EHR) data to forecast patients’ readmission risk during index hospitalizations. Objective We used machine learning and in-hospital data to model 90-day risk for and cause of readmission among inpatients with acute exacerbations of COPD (AE-COPD). Design Retrospective cohort study. Participants Adult patients admitted for AE-COPD at the University of Chicago Medicine between November 7, 2008 and December 31, 2018 meeting International Classification of Diseases (ICD)-9 or −10 criteria consistent with AE-COPD were included. Methods Random forest models were fit to predict readmission risk and respiratory-related readmission cause. Predictor variables included demographics, comorbidities, and EHR data from patients’ index hospital stays. Models were derived on 70% of observations and validated on a 30% holdout set. Performance of the readmission risk model was compared to that of the HOSPITAL score. Results Among 3238 patients admitted for AE-COPD, 1103 patients were readmitted within 90 days. Of the readmission causes, 61% (n = 672) were respiratory-related and COPD (n = 452) was the most common. Our readmission risk model had a significantly higher area under the receiver operating characteristic curve (AUROC) (0.69 [0.66, 0.73]) compared to the HOSPITAL score (0.63 [0.59, 0.67]; p = 0.002). The respiratory-related readmission cause model had an AUROC of 0.73 [0.68, 0.79]. Conclusion Our models improve on current tools by predicting 90-day readmission risk and cause at the time of discharge from index admissions for AE-COPD. These models could be used to identify patients at higher risk of readmission and direct tailored post-discharge transition of care interventions that lower readmission risk.
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Affiliation(s)
- Matthew Bonomo
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Michael G Hermsen
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Samuel Kaskovich
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | | | - Juan C Rojas
- Department of Medicine, Section of Pulmonary/Critical Care, University of Chicago, Chicago, IL, USA
| | - Kyle A Carey
- Department of Medicine, Section of General Internal Medicine, University of Chicago, Chicago, IL, USA
| | - Laura Ruth Venable
- Department of Medicine, Section of Hospitalist Medicine, University of Chicago, Chicago, IL, USA
| | - Matthew M Churpek
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, University of Wisconsin-Madison, Madison, WI, USA
| | - Valerie G Press
- Department of Medicine, Section of General Internal Medicine, University of Chicago, Chicago, IL, USA,Department of Pediatrics, Section of Academic Pediatrics, University of Chicago, Chicago, IL, USA,Correspondence: Valerie G Press, University of Chicago, 5841 S Maryland, MC 2007, Chicago, IL, 60637, USA, Tel +773-702-5170, Email
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13
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Czira A, Banks V, Requena G, Wood R, Tritton T, Wild R, Compton C, Duarte M, Ismaila AS. Characterisation of patients with chronic obstructive pulmonary disease initiating single-device inhaled corticosteroids/long-acting β 2-agonist dual therapy in a primary care setting in England. BMJ Open Respir Res 2022; 9:9/1/e001243. [PMID: 36171051 PMCID: PMC9528685 DOI: 10.1136/bmjresp-2022-001243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 08/27/2022] [Indexed: 11/09/2022] Open
Abstract
Introduction Treatment pathways of patients with chronic obstructive pulmonary disease (COPD) receiving single-device dual therapies in England remain unclear. This study describes the characteristics of patients with COPD before initiating treatment with a single-device inhaled corticosteroid/long-acting β2-agonist (ICS/LABA) in primary care in England. Methods This is a retrospective, descriptive study of linked primary and secondary healthcare data (Clinical Practice Research Datalink Aurum, Hospital Episode Statistics). Patients with COPD were indexed on first prescription of fixed-dose, single-device ICS/LABA (June 2015–December 2018). Demographics, clinical characteristics, prescribed treatments, healthcare resource use (HCRU) and direct healthcare costs were assessed over 12 months pre-index. Incident users (indexed on first ever prescription) could be non-triple users (no concomitant long-acting muscarinic antagonist at index); a subset were initial maintenance therapy (IMT) users (no history of pre-index maintenance therapy). Results Overall, 13 451 incident users (non-triple users: 7448, 55.4%; IMT users: 5162, 38.4%) were indexed on beclomethasone dipropionate/formoterol (6122, 45.5%), budesonide/formoterol (2703, 20.1%) or Other ICS/LABA combinations (4626, 34.4%). Overall, 20.8% of incident users had comorbid asthma and 42.6% had ≥1 moderate-to-severe acute exacerbation of COPD pre-index. Baseline characteristics were similar across indexed therapies. At 3 months pre-index, 45.3% and 35.4% of non-triple and IMT users were receiving maintenance treatment. HCRU and direct healthcare costs were similar across indexed treatments. Prescribing patterns varied regionally. Conclusion Patient characteristics, prior treatments, prior COPD-related HCRU and direct healthcare costs were similar across single-device ICS/LABAs in primary care in England. A high proportion of patients were not receiving any respiratory medication pre-index, indicating that prescribing in primary care in England is more closely aligned with national guidelines than global treatment strategies. Comorbid asthma may have influenced prescribing decisions. Less than half of users had preindex exacerbations, suggesting that ICS/LABA is not being prescribed principally based on exacerbation history.
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Affiliation(s)
- Alexandrosz Czira
- Value Evidence and Outcomes, GSK, R&D Global Medical, Brentford, Middlesex, UK
| | - Victoria Banks
- Real-World Evidence, Adelphi Real World, Bollington, Cheshire, UK
| | - Gema Requena
- Value Evidence and Outcomes, GSK, R&D Global Medical, Brentford, Middlesex, UK
| | - Robert Wood
- Real-World Evidence, Adelphi Real World, Bollington, Cheshire, UK
| | - Theo Tritton
- Real-World Evidence, Adelphi Real World, Bollington, Cheshire, UK
| | - Rosie Wild
- Real-World Evidence, Adelphi Real World, Bollington, Cheshire, UK
| | - Chris Compton
- Value Evidence and Outcomes, GSK, R&D Global Medical, Brentford, Middlesex, UK
| | - Maria Duarte
- Value Evidence and Outcomes, GSK, R&D Global Medical, Brentford, Middlesex, UK
| | - Afisi S Ismaila
- Value Evidence and Outcomes, GSK, Collegeville, Pennsylvania, USA.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
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Stewart NH, Brittan M, McElligott M, Summers MO, Samson K, Press VG. Evaluating the Relationship of Airflow Obstruction in COPD with Severity of OSA Among Patients with Overlap Syndrome. Int J Chron Obstruct Pulmon Dis 2022; 17:1613-1621. [PMID: 35860813 PMCID: PMC9293369 DOI: 10.2147/copd.s355897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 07/04/2022] [Indexed: 11/23/2022] Open
Abstract
Background Chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA) are common diseases affecting millions worldwide. These two diseases have a complex relationship that is not well understood. Previous small studies suggest an inverse relationship of disease severity of OSA with COPD airflow obstruction. Objective The aim of this study was to determine if a relationship exists between severity of airflow obstruction in COPD and severity of OSA via apnea hypopnea index obtained during an in-lab baseline polysomnogram using a large quaternary care center cohort. Methods From November 2015 through December 2018, 273 patients with confirmed COPD via spirometry and OSA via in-lab baseline polysomnogram were included. Conclusion No associations were noted between severity of airflow obstruction in COPD and disease severity of OSA. Given the heterogeneity of these diseases, further exploration of a relationship within disease subtypes is warranted.
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Affiliation(s)
- Nancy H Stewart
- Department of Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Mollie Brittan
- Department of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Maureen McElligott
- Department of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Michael O Summers
- Department of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Kaeli Samson
- Department of Biostatistics, University of Nebraska Medical Center, Omaha, NE, USA
| | - Valerie G Press
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
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15
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Masud JHB, Shun C, Kuo CC, Islam MM, Yeh CY, Yang HC, Lin MC. Deep-ADCA: Development and Validation of Deep Learning Model for Automated Diagnosis Code Assignment Using Clinical Notes in Electronic Medical Records. J Pers Med 2022; 12:jpm12050707. [PMID: 35629129 PMCID: PMC9146030 DOI: 10.3390/jpm12050707] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 04/24/2022] [Accepted: 04/26/2022] [Indexed: 12/04/2022] Open
Abstract
Currently, the International Classification of Diseases (ICD) codes are being used to improve clinical, financial, and administrative performance. Inaccurate ICD coding can lower the quality of care, and delay or prevent reimbursement. However, selecting the appropriate ICD code from a patient’s clinical history is time-consuming and requires expert knowledge. The rapid spread of electronic medical records (EMRs) has generated a large amount of clinical data and provides an opportunity to predict ICD codes using deep learning models. The main objective of this study was to use a deep learning-based natural language processing (NLP) model to accurately predict ICD-10 codes, which could help providers to make better clinical decisions and improve their level of service. We retrospectively collected clinical notes from five outpatient departments (OPD) from one university teaching hospital between January 2016 and December 2016. We applied NLP techniques, including global vectors, word to vectors, and embedding techniques to process the data. The dataset was split into two independent training and testing datasets consisting of 90% and 10% of the entire dataset, respectively. A convolutional neural network (CNN) model was developed, and the performance was measured using the precision, recall, and F-score. A total of 21,953 medical records were collected from 5016 patients. The performance of the CNN model for the five different departments was clinically satisfactory (Precision: 0.50~0.69 and recall: 0.78~0.91). However, the CNN model achieved the best performance for the cardiology department, with a precision of 69%, a recall of 89% and an F-score of 78%. The CNN model for predicting ICD-10 codes provides an opportunity to improve the quality of care. Implementing this model in real-world clinical settings could reduce the manual coding workload, enhance the efficiency of clinical coding, and support physicians in making better clinical decisions.
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Affiliation(s)
- Jakir Hossain Bhuiyan Masud
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei 11031, Taiwan; (J.H.B.M.); (C.S.); (C.-C.K.); (C.-Y.Y.)
| | - Chiang Shun
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei 11031, Taiwan; (J.H.B.M.); (C.S.); (C.-C.K.); (C.-Y.Y.)
- Department of Otolaryngology, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan
| | - Chen-Cheng Kuo
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei 11031, Taiwan; (J.H.B.M.); (C.S.); (C.-C.K.); (C.-Y.Y.)
| | - Md. Mohaimenul Islam
- International Center for Health Information Technology (ICHIT), College of Medical Science and Technology, Taipei Medical University, Taipei 11031, Taiwan;
- Research Center of Big Data and Meta-Analysis, Wan Fang Hospital, Taipei Medical University, Taipei 11696, Taiwan
- AESOP Technology, Taipei 10596, Taiwan
| | - Chih-Yang Yeh
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei 11031, Taiwan; (J.H.B.M.); (C.S.); (C.-C.K.); (C.-Y.Y.)
| | - Hsuan-Chia Yang
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei 11031, Taiwan; (J.H.B.M.); (C.S.); (C.-C.K.); (C.-Y.Y.)
- International Center for Health Information Technology (ICHIT), College of Medical Science and Technology, Taipei Medical University, Taipei 11031, Taiwan;
- Clinical Big Data Research Center, Taipei Medical University Hospital, Taipei 11031, Taiwan
- Correspondence: (H.-C.Y.); (M.-C.L.)
| | - Ming-Chin Lin
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei 11031, Taiwan; (J.H.B.M.); (C.S.); (C.-C.K.); (C.-Y.Y.)
- Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan
- Taipei Neuroscience Institute, Taipei Medical University, Taipei 11031, Taiwan
- Correspondence: (H.-C.Y.); (M.-C.L.)
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Kelly TL, Ward M, Pratt NL, Ramsay E, Gillam M, Roughead EE. The association between exacerbation of chronic obstructive pulmonary disease and timing of paracetamol use: a cohort study in elderly Australians. Respir Res 2022; 23:80. [PMID: 35382818 PMCID: PMC8979782 DOI: 10.1186/s12931-022-02010-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 03/29/2022] [Indexed: 12/02/2022] Open
Abstract
Background In elderly populations, paracetamol may be used regularly for conditions such as osteoarthritis. Paracetamol has been associated with respiratory disease through a proposed mechanism of glutathione depletion and oxidative stress. Given that chronic obstructive pulmonary disease (COPD) is frequently co-morbid with osteoarthritis, this study investigated whether the dose and timing of paracetamol exposure may induce COPD exacerbations. Methods The study population was 3523 Australian Government Department of Veterans’ Affairs full entitlement holders who had existing COPD on 1 January 2011, who were dispensed at least one prescription of paracetamol between 1 January 2011 and 30 September 2015, and had no paracetamol dispensed in the 6 months prior to 1 January 2011. The outcome was time to first hospitalisation for COPD exacerbation after initiation of paracetamol. A weighted cumulative exposure approach was used. Results The association between paracetamol exposure and COPD exacerbation was protective or harmful depending on the dose, duration, and recency of exposure. Compared to non-use, current use at the maximum dose of 4 g daily for 7 days was associated with a lower risk (HR = 0.78, 95% CI = 0.67–0.92) and a higher risk after 30 days (HR = 1.27, 95% CI = 1.06–1.52). Risk declined to baseline after 2 months. For past use, there was a short-term increase in risk on discontinuation depending of dose, duration and time since stopping. Conclusions Patients and doctors should be aware of the possible risk of COPD exacerbation with higher dose paracetamol 1 to 6 weeks after initiation or discontinuation, but no increased risk after 2 months. Supplementary Information The online version contains supplementary material available at 10.1186/s12931-022-02010-z.
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Affiliation(s)
- Thu-Lan Kelly
- Clinical and Health Sciences, Quality Use of Medicines Pharmacy Research Centre, University of South Australia, Adelaide, Australia.
| | - Michael Ward
- Clinical and Health Sciences, University of South Australia, Adelaide, Australia
| | - Nicole L Pratt
- Clinical and Health Sciences, Quality Use of Medicines Pharmacy Research Centre, University of South Australia, Adelaide, Australia
| | - Emmae Ramsay
- Clinical and Health Sciences, Quality Use of Medicines Pharmacy Research Centre, University of South Australia, Adelaide, Australia
| | - Marianne Gillam
- Clinical and Health Sciences, Quality Use of Medicines Pharmacy Research Centre, University of South Australia, Adelaide, Australia
| | - Elizabeth E Roughead
- Clinical and Health Sciences, Quality Use of Medicines Pharmacy Research Centre, University of South Australia, Adelaide, Australia
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Gupta A, McKeever TM, Hutchinson JP, Bolton CE. Impact of Coexisting Dementia on Inpatient Outcomes for Patients Admitted with a COPD Exacerbation. Int J Chron Obstruct Pulmon Dis 2022; 17:535-544. [PMID: 35300119 PMCID: PMC8921839 DOI: 10.2147/copd.s345751] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 02/03/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose People with COPD are at a higher risk of cognitive dysfunction than the general population. However, the additional impact of dementia amongst such patients is not well understood, particularly in those admitted with a COPD exacerbation. We assessed the impact of coexisting dementia on inpatient mortality and length of stay (LOS) in patients admitted to hospital with a COPD exacerbation, using the United States based National Inpatient Sample database. Patients and Methods Patients aged over 40 years and hospitalised with a primary diagnosis of COPD exacerbation from 2011 to 2015 were included. Cases were grouped into patients with and without dementia. Multivariable logistic regression analysis, stratified by age, was used to assess risk of inpatient deaths. Cox regression was carried out to compare death rates and competing risk analysis gave estimates of discharge rates with time to death a competing variable. Results A total of 576,381 patients were included into the analysis, of which 35,372 (6.1%) had co-existent dementia. There were 6413 (1.1%) deaths recorded. The odds of inpatient death were significantly greater in younger patients with dementia (41–64 years) [OR (95% CI) dementia vs without: 1.75 (1.04–2.92), p=0.03]. Cases with dementia also had a higher inpatient mortality rate in the first 4 days [HR (95% CI) dementia vs without: 1.23 (1.08–1.41), p=0.002] and a longer LOS [sub-hazard ratio (95% CI) dementia vs without: 0.93 (0.92–0.94), p<0.001]. Conclusion Dementia as a comorbidity is associated with worse outcomes based on inpatient deaths and LOS in patients admitted with COPD exacerbations.
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Affiliation(s)
- Ayushman Gupta
- NIHR Nottingham BRC Respiratory Theme, Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham, UK
| | - Tricia M McKeever
- NIHR Nottingham BRC Respiratory Theme, Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham, UK
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - John P Hutchinson
- Respiratory Medicine, Sherwood Forest Hospitals NHS Foundation Trust, Sutton-in-Ashfield, UK
| | - Charlotte E Bolton
- NIHR Nottingham BRC Respiratory Theme, Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham, UK
- Correspondence: Charlotte E Bolton, B22, NIHR Nottingham BRC respiratory theme, Translational Medical Sciences, School of Medicine, University of Nottingham, Clinical Sciences Building, City Hospital Campus, Hucknall road, Nottingham, NG5 1PB, UK, Email
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Zeng S, Arjomandi M, Tong Y, Liao ZC, Luo G. Developing a Machine Learning Model to Predict Severe Chronic Obstructive Pulmonary Disease Exacerbations: Retrospective Cohort Study. J Med Internet Res 2022; 24:e28953. [PMID: 34989686 PMCID: PMC8778560 DOI: 10.2196/28953] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 07/03/2021] [Accepted: 11/19/2021] [Indexed: 12/14/2022] Open
Abstract
Background Chronic obstructive pulmonary disease (COPD) poses a large burden on health care. Severe COPD exacerbations require emergency department visits or inpatient stays, often cause an irreversible decline in lung function and health status, and account for 90.3% of the total medical cost related to COPD. Many severe COPD exacerbations are deemed preventable with appropriate outpatient care. Current models for predicting severe COPD exacerbations lack accuracy, making it difficult to effectively target patients at high risk for preventive care management to reduce severe COPD exacerbations and improve outcomes. Objective The aim of this study is to develop a more accurate model to predict severe COPD exacerbations. Methods We examined all patients with COPD who visited the University of Washington Medicine facilities between 2011 and 2019 and identified 278 candidate features. By performing secondary analysis on 43,576 University of Washington Medicine data instances from 2011 to 2019, we created a machine learning model to predict severe COPD exacerbations in the next year for patients with COPD. Results The final model had an area under the receiver operating characteristic curve of 0.866. When using the top 9.99% (752/7529) of the patients with the largest predicted risk to set the cutoff threshold for binary classification, the model gained an accuracy of 90.33% (6801/7529), a sensitivity of 56.6% (103/182), and a specificity of 91.17% (6698/7347). Conclusions Our model provided a more accurate prediction of severe COPD exacerbations in the next year compared with prior published models. After further improvement of its performance measures (eg, by adding features extracted from clinical notes), our model could be used in a decision support tool to guide the identification of patients with COPD and at high risk for care management to improve outcomes. International Registered Report Identifier (IRRID) RR2-10.2196/13783
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Affiliation(s)
- Siyang Zeng
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, WA, United States
| | - Mehrdad Arjomandi
- Medical Service, San Francisco Veterans Affairs Medical Center, San Francisco, CA, United States.,Department of Medicine, University of California, San Francisco, CA, United States
| | - Yao Tong
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, WA, United States
| | - Zachary C Liao
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, WA, United States
| | - Gang Luo
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, WA, United States
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Wan ES, Balte P, Schwartz JE, Bhatt SP, Cassano PA, Couper D, Daviglus ML, Dransfield MT, Gharib SA, Jacobs DR, Kalhan R, London SJ, Acien AN, O’Connor GT, Sanders JL, Smith BM, White W, Yende S, Oelsner EC. Association Between Preserved Ratio Impaired Spirometry and Clinical Outcomes in US Adults. JAMA 2021; 326:2287-2298. [PMID: 34905031 PMCID: PMC8672237 DOI: 10.1001/jama.2021.20939] [Citation(s) in RCA: 69] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 11/03/2021] [Indexed: 11/14/2022]
Abstract
Importance Chronic lung diseases are a leading cause of morbidity and mortality. Unlike chronic obstructive pulmonary disease, clinical outcomes associated with proportional reductions in expiratory lung volumes without obstruction, otherwise known as preserved ratio impaired spirometry (PRISm), are poorly understood. Objective To examine the prevalence, correlates, and clinical outcomes associated with PRISm in US adults. Design, Setting, and Participants The National Heart, Lung, and Blood Institute (NHLBI) Pooled Cohorts Study was a retrospective study with harmonized pooled data from 9 US general population-based cohorts (enrollment, 65 251 participants aged 18 to 102 years of whom 53 701 participants had valid baseline lung function) conducted from 1971-2011 (final follow-up, December 2018). Exposures Participants were categorized into mutually exclusive groups by baseline lung function. PRISm was defined as the ratio of forced expiratory volume in the first second to forced vital capacity (FEV1:FVC) greater than or equal to 0.70 and FEV1 less than 80% predicted; obstructive spirometry FEV1:FVC ratio of less than 0.70; and normal spirometry FEV1:FVC ratio greater than or equal to 0.7 and FEV1 greater than or equal to 80% predicted. Main Outcomes and Measures Main outcomes were all-cause mortality, respiratory-related mortality, coronary heart disease (CHD)-related mortality, respiratory-related events (hospitalizations and mortality), and CHD-related events (hospitalizations and mortality) classified by adjudication or validated administrative criteria. Absolute risks were adjusted for age and smoking status. Poisson and Cox proportional hazards models comparing PRISm vs normal spirometry were adjusted for age, sex, race and ethnicity, education, body mass index, smoking status, cohort, and comorbidities. Results Among all participants (mean [SD] age, 53.2 [15.8] years, 56.4% women, 48.5% never-smokers), 4582 (8.5%) had PRISm. The presence of PRISm relative to normal spirometry was significantly associated with obesity (prevalence, 48.3% vs 31.4%; prevalence ratio [PR], 1.68 [95% CI, 1.55-1.82]), underweight (prevalence, 1.4% vs 1.0%; PR, 2.20 [95% CI, 1.72-2.82]), female sex (prevalence, 60.3% vs 59.0%; PR, 1.07 [95% CI, 1.01-1.13]), and current smoking (prevalence, 25.2% vs 17.5%; PR, 1.33 [95% CI, 1.22-1.45]). PRISm, compared with normal spirometry, was significantly associated with greater all-cause mortality (29.6/1000 person-years vs 18.0/1000 person-years; difference, 11.6/1000 person-years [95% CI, 10.0-13.1]; adjusted hazard ratio [HR], 1.50 [95% CI, 1.42-1.59]), respiratory-related mortality (2.1/1000 person-years vs 1.0/1000 person-years; difference, 1.1/1000 person-years [95% CI, 0.7-1.6]; adjusted HR, 1.95 [95% CI, 1.54-2.48]), CHD-related mortality (5.4/1000 person-years vs 2.6/1000 person-years; difference, 2.7/1000 person-years [95% CI, 2.1-3.4]; adjusted HR, 1.55 [95% CI, 1.36-1.77]), respiratory-related events (12.2/1000 person-years vs 6.0/1000 person-years; difference, 6.2/1000 person-years [95% CI, 4.9-7.5]; adjusted HR, 1.90 [95% CI, 1.69-2.14]), and CHD-related events (11.7/1000 person-years vs 7.0/1000 person-years; difference, 4.7/1000 person-years [95% CI, 3.7-5.8]; adjusted HR, 1.30 [95% CI, 1.18-1.42]). Conclusions and Relevance In a large, population-based sample of US adults, baseline PRISm, compared with normal spirometry, was associated with a small but statistically significant increased risk for mortality and adverse cardiovascular and respiratory outcomes. Further research is needed to explore whether this association is causal.
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Affiliation(s)
- Emily S. Wan
- Channing Division of Network Medicine, Brigham & Women’s Hospital, Boston, Massachusetts
- VA Boston Healthcare System, Boston, Massachusetts
| | | | - Joseph E. Schwartz
- Columbia University, New York, New York
- Renaissance School of Medicine at Stony Brook University, Stony Brook, New York
| | | | | | | | - Martha L. Daviglus
- Institute for Minority Health Research, University of Illinois College of Medicine, Chicago
| | | | - Sina A. Gharib
- Computational Medicine Core, Center for Lung Biology, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle
| | | | | | - Stephanie J. London
- National Institute of Environmental Health Sciences, National Institutes of Health, Department of Health and Human Services, Research Triangle Park, North Carolina
| | | | | | - Jason L. Sanders
- Division of Pulmonary and Critical Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | | | - Sachin Yende
- University of Pittsburgh, Pittsburgh, Pennsylvania
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20
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Sun SH, Chang CH, Zhan ZW, Chang WH, Chen YA, Dong YH. Risk of COPD Exacerbations Associated with Statins versus Fibrates: A New User, Active Comparison, and High-Dimensional Propensity Score Matched Cohort Study. Int J Chron Obstruct Pulmon Dis 2021; 16:2721-2733. [PMID: 34621122 PMCID: PMC8491865 DOI: 10.2147/copd.s323391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 09/03/2021] [Indexed: 11/23/2022] Open
Abstract
Background Several observational studies have found that statins may materially decrease the risk of chronic obstructive pulmonary disease (COPD) exacerbations. However, most of these studies used a prevalent user, non-user comparison approach, which may lead to overestimation of the clinical benefits of statins. We aimed to explore the risk of COPD exacerbations associated with statins with a new user, active comparison approach to address potential methodological concerns. We selected fibrates, another class of lipid-lowering agents, as the reference group because no evidence suggests that fibrates have an effect on COPD exacerbations. Methods We identified patients with COPD who initiated statins or fibrates from a nationwide Taiwanese database. Patients were followed from cohort entry to the earliest of the following: hospitalization for COPD exacerbations, death, end of the data, or 180 days after cohort entry. Stratified Cox regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) of COPD exacerbations comparing statins with fibrates after variable-ratio propensity score (PS) matching and high-dimensional PS (hd-PS) matching, respectively. Results We identified a total of 134,909 eligible patients (110,726 initiated statins; 24,183 initiated fibrates); 1979 experienced COPD exacerbations during follow-up. The HRs were 1.10 (95% CI, 0.96 to 1.26) after PS matching and 1.08 (95% CI, 0.94 to 1.24) after hd-PS matching. The results did not differ materially by type of statins and patient characteristic and did not change with longer follow-up durations. Conclusion This large-scale, population-based cohort study did not show that use of statins was associated with a reduced risk of acute exacerbations in patients with COPD using state-of-the-art pharmacoepidemiologic approaches. The findings emphasize the importance of applying appropriate methodology in exploring statin effectiveness in real-world settings.
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Affiliation(s)
- Shu-Hui Sun
- Department of Pharmacy, Far Eastern Memorial Hospital, Banciao, New Taipei City, Taiwan
| | - Chia-Hsuin Chang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Department of Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.,Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Zhe-Wei Zhan
- Department of Pharmacy, College of Pharmaceutical Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wen-Hsuan Chang
- Department of Pharmacy, College of Pharmaceutical Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yu-An Chen
- Institute of Public Health, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yaa-Hui Dong
- Department of Pharmacy, College of Pharmaceutical Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Institute of Public Health, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Institute of Hospital and Health Care Administration, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
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21
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Woodhouse DC, Frolkis AD, Murray BJ, Solbak NM, Samardzic N, Burak KW. The Impact of Comorbidities on Calgary Hospital Utilization in Patients With Chronic Obstructive Pulmonary Disease and Heart Failure. Cureus 2021; 13:e17303. [PMID: 34552837 PMCID: PMC8449541 DOI: 10.7759/cureus.17303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2021] [Indexed: 11/06/2022] Open
Abstract
Background Chronic obstructive pulmonary disease (COPD) and heart failure (HF) are chronic conditions with high acute care utilization. Disease-specific order sets were developed for patients with COPD or HF in Calgary to reduce total days in hospital for this population of patients. However, many patients have comorbidities which may contribute to hospital utilization; thus, disease-specific order sets may not be an optimal solution to reduce overall acute care utilization. Methods Inpatient data on Calgary hospitalizations for COPD or HF between April 1, 2017 - March 31, 2019 and associated diagnoses were identified. Outcomes included total days in hospital and length of stay for COPD and HF patients stratified by number of comorbidities. Results Total days in hospital increased with the number of comorbidities for both conditions. During the study period, 131 patients with COPD and no comorbidities had a median length of stay of three days (IQR: 3) compared to 3,911 COPD patients with one to five comorbidities with a median length of stay of seven days (IQR: 9). There were 47 patients with HF and no comorbidities with a median length of stay of four days (IQR: 5) compared to 6,273 HF patients with one to five comorbidities with a median length of stay of nine days (IQR: 12). Common comorbidities included hypertension, type 2 diabetes, and acute renal failure. COPD and HF are frequently comorbid. Conclusions Total days in hospital for patients with COPD or HF is positively correlated with the number of comorbidities. COPD or HF patients with between one to five comorbidities (compared to those with no comorbidities, and those with more than five comorbidities) represent the majority of total days in hospital, and the majority of patients. This highlights the importance of focusing on patients with comorbidities in efforts to reduce hospital utilization, and suggests that concurrent management of commonly occurring comorbidities for HF and COPD patients may be necessary to achieve this goal.
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Affiliation(s)
| | | | | | | | | | - Kelly W Burak
- Internal Medicine, University of Calgary, Calgary, CAN
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22
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Le TT, Qato DM, Magder L, Bjarnadóttir M, Zafari Z, Simoni-Wastila L. Prevalence and Newly Diagnosed Rates of Multimorbidity in Older Medicare Beneficiaries with COPD. COPD 2021; 18:541-548. [PMID: 34468243 DOI: 10.1080/15412555.2021.1968815] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Few studies have quantified the multimorbidity burden in older adults with chronic obstructive pulmonary disease (COPD) using large and generalizable data. Such evidence is essential to inform evidence-based research, clinical care, and resource allocation. This retrospective cohort study used a nationally representative sample of Medicare beneficiaries aged 65 years or older with COPD and 1:1 matched (on age, sex, and race) non-COPD beneficiaries to: (1) quantify the prevalence of multimorbidity at COPD onset and one-year later; (2) quantify the rates [per 100 person-years (PY)] of newly diagnosed multimorbidity during in the year prior to and in the year following COPD onset; and (3) compare multimorbidity prevalence in beneficiaries with and without COPD. Among 739,118 eligible beneficiaries with and without COPD, the average number of multimorbidity was 10.0 (SD = 4.7) and 1.0 (SD = 3.3), respectively. The most prevalent multimorbidity at COPD onset and at one-year after, respectively, were hypertension (70.8% and 80.2%), hyperlipidemia (52.2% and 64.8%), anemia (42.1% and 52.0%), arthritis (39.8% and 47.7%), and congestive heart failure (CHF) (31.3% and 38.8%). Conditions with the highest newly diagnosed rates before and following COPD onset, respectively, included hypertension (39.8 and 32.3 per 100 PY), hyperlipidemia (22.8 and 27.6), anemia (17.8 and 20.3), CHF (16.2 and 13.2), and arthritis (12.9 and 13.2). COPD was significantly associated with increased odds of all measured conditions relative to non-COPD controls. This study updates existing literature with more current, generalizable findings of the substantial multimorbidity burden in medically complex older adults with COPD-necessary to inform patient-centered, multidimensional care.Supplemental data for this article is available online at https://doi.org/10.1080/15412555.2021.1968815 .
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Affiliation(s)
- Tham T Le
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, MD, USA.,Peter Lamy Center for Drug Therapeutic and Aging, University of Maryland, College Park, MD, USA
| | - Danya M Qato
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, MD, USA.,Peter Lamy Center for Drug Therapeutic and Aging, University of Maryland, College Park, MD, USA.,Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Larry Magder
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Margrét Bjarnadóttir
- Department of Decision, Operation, and Information Technologies, University of Maryland, College Park, MD, USA
| | - Zafar Zafari
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Linda Simoni-Wastila
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, MD, USA.,Peter Lamy Center for Drug Therapeutic and Aging, University of Maryland, College Park, MD, USA
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23
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Myers LC, Cash R, Liu VX, Camargo CA. Reducing Readmissions for Chronic Obstructive Pulmonary Disease in Response to the Hospital Readmissions Reduction Program. Ann Am Thorac Soc 2021; 18:1506-1513. [PMID: 33476524 PMCID: PMC8489864 DOI: 10.1513/annalsats.202007-786oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 01/21/2021] [Indexed: 11/20/2022] Open
Abstract
Rationale: In August 2013, the Hospital Readmission Reduction Program announced financial penalties on hospitals with higher than expected risk-adjusted 30-day readmission rates for Medicare beneficiaries hospitalized for chronic obstructive pulmonary disease (COPD) exacerbation. In October 2014, penalties were imposed. We hypothesized that penalties would be associated with decreased readmissions after COPD hospitalizations. Objectives: To determine whether the announcement and enactment of financial penalties for COPD were associated with decreases in hospital readmissions for COPD. Methods: We used data from California's Office of Statewide Health Planning and Development to examine unplanned 30-day all-cause and COPD-related readmissions after COPD hospitalization. The preannouncement period was January 2010 to July 2013. The postannouncement period was August 2013 to September 2014. The postenactment period was October 2014 to December 2017. Using interrupted time series, we investigated the immediate change after the intervention (level change) and differences in the preintervention and postintervention trends (slope change). Results: We identified 333,429 index hospitalizations for COPD from 449 California hospitals. Overall, 69% of patients had Medicare insurance. For all-cause readmissions, the level change at announcement was 0.16% (95% confidence interval [CI], -1.07 to 1.38; P = 0.80); the change in slope between preannouncement and postannouncement periods was -0.01% (95% CI, -0.15 to 0.13; P = 0.92). The level change at enactment was 0.29% (95% CI, -1.11 to 1.69; P = 0.68); the change in slope between postannouncement and postenactment was 0.04% (95% CI, -0.10 to 0.18; P = 0.57). For patients with COPD-related readmissions, the level change at the time of the announcement was 0.09% (95% CI, -0.68 to 0.85; P = 0.83); the change in slope was 0.003% (95% CI, -0.08 to 0.09; P = 0.94). The level change at the time of the enactment was 0.22% (95% CI, -0.69 to 1.12; P = 0.64); the change in slope was -0.02% (95% CI, -0.10 to 0.07; P = 0.72). Conclusions: We did not detect decreases in either all-cause or COPD-related readmission rates at either time point. Although this would suggest that the Hospital Readmission Reduction Program penalty was ineffective for COPD, COPD readmissions had decreased at an earlier time point (October 2012) when penalties were announced for conditions other than COPD. Based on this, we believe early, broad interventions decreased readmissions, such that no difference was seen at this later time points despite institution of COPD-specific penalties.
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Affiliation(s)
- Laura C. Myers
- Division of Research, Kaiser Permanente Northern California, Oakland, California; and
| | - Rebecca Cash
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Vincent X. Liu
- Division of Research, Kaiser Permanente Northern California, Oakland, California; and
| | - Carlos A. Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Monsour E, Rodriguez LM, Abdelmasih R, Tuna K, Abusaada K. Characteristics and outcomes of diabetic patients with acute exacerbation of COPD. J Diabetes Metab Disord 2021; 20:461-6. [PMID: 34178851 DOI: 10.1007/s40200-021-00766-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 02/08/2021] [Indexed: 01/09/2023]
Abstract
Rationale aims and objectives Patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) and diabetes mellitus form a special population due to an increased risk of hyperglycemia from the use of corticosteroids. There is limited data regarding specific outcomes in diabetic patients with AECOPD. Methods A retrospective data analysis of adult patients admitted to North Florida Division of the Hospital Corporation of America (HCA Healthcare) with a primary or secondary diagnosis of AECOPD from January 1, 2018, to December 31, 2018. We excluded patients who needed intensive care unit (ICU) care on day 0. Outcomes assessed included length of stay, mortality, and need for ICU transfer after 48 h from admission. Characteristics included age, sex, and race, comorbidities such as diabetes mellitus, chronic kidney disease, acute kidney injury, congestive heart failure, and anemia were analyzed. Comparisons were analyzed via binary and multivariate logistic regression models. Results A total of 3788 patients admitted for AECOPD were included; amongst them, 1356 patients (~36%) had diabetes mellitus. This subset of patients had higher rates of comorbidities. A significant portion of diabetic patients (72%) received intravenous rather than oral steroids, similar to non-diabetic patients. In addition, diabetic patients were more likely to develop acute kidney injury (14.2% vs 8.0%, p < 0.004) and decompensated heart failure (9.2% vs 4.6%, p < 0.001). Diabetic patients had higher length of stay and increased need for ICU transfer. However, diabetes itself did not independently affect length of stay (CI -0.028, 0.479, p = 0.081) when adjusted to comorbidities and patient's characteristics. Moreover, diabetes was independently associated with an increased need for transfer to ICU (Odds ratio 1.9, p = 0.031). The oral route of steroid use was associated with decreased LOS (β coefficient - 0.9, p < 0.001). Conclusion Diabetes mellitus is independently associated with increased ICU transfers amongst patients hospitalized with AECOPD. The use of oral steroids rather than intravenous steroids was independently associated with decreased length of stay in diabetic and non-diabetic patients. Despite no difference in intravenous vs. oral corticosteroids demonstrated in previous COPD trials, a significant portion of diabetic patients continue to receive intravenous corticosteroids. Further investigation is required to explore these findings.
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Stewart NH, Walters RW, Mokhlesi B, Lauderdale DS, Arora VM. Sleep in hospitalized patients with chronic obstructive pulmonary disease: an observational study. J Clin Sleep Med 2021; 16:1693-1699. [PMID: 32620186 DOI: 10.5664/jcsm.8646] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
STUDY OBJECTIVES The aim of this study was to compare the risk of undiagnosed sleep disorders among medical patients with chronic obstructive pulmonary disease (COPD) compared with those without COPD. METHODS In a prospective cohort study, hospitalized medical ward patients without a known sleep disorder were screened, using validated questionnaires, for sleep disorders, such as obstructive sleep apnea and insomnia. Daily sleep duration and efficiency in the hospital were measured via wrist actigraphy. Participants were classified into two groups: those with a primary or secondary diagnosis of COPD and those without a history of COPD diagnosis. Sleep outcomes were compared by COPD diagnosis. RESULTS From March 2010 to July 2015, 572 patients completed questionnaires and underwent wrist actigraphy. On admission, patients with COPD had a greater adjusted risk of obstructive sleep apnea (adjusted odds ratio 1.82, 95% confidence interval 1.12-2.96, P = .015) and clinically significant insomnia (adjusted odds ratio 2.07, 95% confidence interval 1.12-3.83, P = .021); no differences were observed for sleep quality or excess sleepiness on admission. After adjustment, compared with patients without COPD, patients with COPD averaged 34 fewer minutes of nightly sleep (95% confidence interval 4.2-64.0 minutes, P = .026), as well as 22.5% lower odds of normal sleep efficiency while in the hospital (95% confidence interval 3.3%-37.9%, P = .024). No statistically significant differences were observed for in-hospital sleep quality, soundness, or ease of falling asleep. CONCLUSIONS Among hospitalized patients in medical wards, those with COPD have higher risk of OSA and insomnia and worse in-hospital sleep quality and quantity compared with those without COPD.
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Affiliation(s)
- Nancy H Stewart
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Ryan W Walters
- Department of Medicine, Creighton University, Omaha, Nebraska
| | - Babak Mokhlesi
- Section of Pulmonary, Critical Care, and Sleep Medicine, University of Chicago Medicine, Chicago, Illinois
| | - Diane S Lauderdale
- Department of Public Health Studies, University of Chicago, Chicago, Illinois
| | - Vineet M Arora
- Section of General Internal Medicine, University of Chicago Medical Center, Chicago, Illinois
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Mapel DW, Roberts MH, Sama S, Bobbili PJ, Cheng WY, Duh MS, Nguyen C, Thompson-Leduc P, Van Dyke MK, Rothnie KJ, Sundaresan D, Certa JM, Whiting TS, Brown JL, Roblin DW. Development and Validation of a Healthcare Utilization-Based Algorithm to Identify Acute Exacerbations of Chronic Obstructive Pulmonary Disease. Int J Chron Obstruct Pulmon Dis 2021; 16:1687-1698. [PMID: 34135580 PMCID: PMC8200149 DOI: 10.2147/copd.s302241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 05/09/2021] [Indexed: 12/02/2022] Open
Abstract
Introduction Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are important events that may precipitate other adverse outcomes. Accurate AECOPD event identification in electronic administrative data is essential for improving population health surveillance and practice management. Objective Develop codified algorithms to identify moderate and severe AECOPD in two US healthcare systems using administrative data and electronic medical records, and validate their performance by calculating positive predictive value (PPV) and negative predictive value (NPV). Methods Data from two large regional integrated health systems were used. Eligible patients were identified using International Classification of Diseases (Ninth Edition) COPD diagnosis codes. Two algorithms were developed: one to identify potential moderate AECOPD by selecting outpatient/emergency visits associated with AECOPD-related codes and antibiotic/systemic steroid prescriptions; the other to identify potential severe AECOPD by selecting inpatient visits associated with corresponding codes. Algorithms were validated via patient chart review, adjudicated by a pulmonologist. To estimate PPV, 300 potential moderate AECOPD and 250 potential severe AECOPD events underwent review. To estimate NPV, 200 patients without any AECOPD identified by the algorithms (100 patients each without moderate or severe AECOPD) during the two years following the index date underwent review to identify AECOPD missed by the algorithm (false negatives). Results The PPVs (95% confidence interval [CI]) for both moderate and severe AECOPD were high: 293/298 (98.3% [96.1–99.5]) and 216/225 (96.0% [92.5–98.2]), respectively. NPV was lower for moderate AECOPD (75.0% [65.3–83.1]) than for severe AECOPD (95.0% [88.7–98.4]). Results were consistent across both healthcare systems. Conclusion This study developed healthcare utilization-based algorithms to identify moderate and severe AECOPD in two separate healthcare systems. PPV for both algorithms was high; NPV was lower for the moderate algorithm. Replication and consistency of results across two healthcare systems support the external validity of these findings.
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Affiliation(s)
- Douglas W Mapel
- College of Pharmacy, University of New Mexico, Albuquerque, NM, USA
| | | | - Susan Sama
- Reliant Medical Group, Inc., Worcester, MA, USA
| | | | | | | | | | | | | | | | | | - Julia M Certa
- Kaiser Permanente Mid-Atlantic States (KPMAS), Mid-Atlantic Permanente Research Institute (MAPRI), Rockville, MD, USA
| | - Thomas S Whiting
- Kaiser Permanente Mid-Atlantic States (KPMAS), Mid-Atlantic Permanente Research Institute (MAPRI), Rockville, MD, USA
| | - Jennifer L Brown
- Kaiser Permanente Mid-Atlantic States (KPMAS), Mid-Atlantic Permanente Research Institute (MAPRI), Rockville, MD, USA
| | - Douglas W Roblin
- Kaiser Permanente Mid-Atlantic States (KPMAS), Mid-Atlantic Permanente Research Institute (MAPRI), Rockville, MD, USA
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Albogami Y, Cusi K, Daniels MJ, Wei YJJ, Winterstein AG. Glucagon-Like Peptide 1 Receptor Agonists and Chronic Lower Respiratory Disease Exacerbations Among Patients With Type 2 Diabetes. Diabetes Care 2021; 44:1344-1352. [PMID: 33875487 PMCID: PMC8247488 DOI: 10.2337/dc20-1794] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 03/01/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Emerging data from animal and human pilot studies suggest potential benefits of glucagon-like peptide 1 receptor agonists (GLP-1RA) on lung function. We aimed to assess the association of GLP-1RA and chronic lower respiratory disease (CLRD) exacerbation in a population with comorbid type 2 diabetes (T2D) and CLRD. RESEARCH DESIGN AND METHODS A new-user active-comparator analysis was conducted with use of a national claims database of beneficiaries with employer-sponsored health insurance spanning 2005-2017. We included adults with T2D and CLRD who initiated GLP-1RA or dipeptidyl peptidase 4 inhibitors (DPP-4I) as an add-on therapy to their antidiabetes regimen. The primary outcome was time to first hospital admission for CLRD. The secondary outcome was a count of any CLRD exacerbation associated with an inpatient or outpatient visit. We estimated incidence rates using inverse probability of treatment weighting for each study group and compared via risk ratios. RESULTS The study sample consisted of 4,150 GLP-1RA and 12,540 DPP-4I new users with comorbid T2D and CLRD. The adjusted incidence rate of first CLRD admission during follow-up was 10.7 and 20.3 per 1,000 person-years for GLP-1RA and DPP-4I users, respectively, resulting in an adjusted hazard ratio of 0.52 (95% CI 0.32-0.85). For the secondary outcome, the adjusted incidence rate ratio was 0.70 (95% CI 0.57-0.87). CONCLUSIONS GLP-1RA users had fewer CLRD exacerbations in comparison with DPP-4I users. Considering both plausible mechanistic pathways and this real-world evidence, potential beneficial effects of GLP-1RA may be considered in selection of an antidiabetes treatment regimen. Randomized clinical trials are warranted to confirm our findings.
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Affiliation(s)
- Yasser Albogami
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL .,Center for Drug Evaluation and Safety, University of Florida, Gainesville, FL.,Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Kenneth Cusi
- Division of Endocrinology, Diabetes and Metabolism, University of Florida, Gainesville, FL
| | | | - Yu-Jung J Wei
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL.,Center for Drug Evaluation and Safety, University of Florida, Gainesville, FL
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL.,Center for Drug Evaluation and Safety, University of Florida, Gainesville, FL
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Lu CH, Clark CM, Tober R, Allen M, Gibson W, Bednarczyk EM, Daly CJ, Jacobs DM. Readmissions and costs among younger and older adults for targeted conditions during the enactment of the hospital readmission reduction program. BMC Health Serv Res 2021; 21:386. [PMID: 33902569 PMCID: PMC8077835 DOI: 10.1186/s12913-021-06399-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 04/15/2021] [Indexed: 11/17/2022] Open
Abstract
Background The Hospital Readmissions Reduction Program (HRRP) was introduced to reduce readmission rates among Medicare beneficiaries, however little is known about readmissions and costs for HRRP-targeted conditions in younger populations. The primary objective of this study was to examine readmission trends and costs for targeted conditions during policy implementation among younger and older adults in the U.S. Methods We analyzed the Nationwide Readmission Database from January 2010 to September 2015 in younger (18–64 years) and older (≥65 years) patients with acute myocardial infarction (AMI), heart failure (HF), pneumonia, and acute exacerbations of chronic obstructive pulmonary disease (AECOPD). Pre- and post-HRRP periods were defined based on implementation of the policy for each condition. Readmission rates were evaluated using an interrupted time series with difference-in-difference analyses and hospital cost differences between early and late readmissions (≤30 vs. > 30 days) were evaluated using generalized linear models. Results Overall, this study included 16,884,612 hospitalizations with 3,337,266 readmissions among all age groups and 5,977,177 hospitalizations with 1,104,940 readmissions in those aged 18–64 years. Readmission rates decreased in all conditions. In the HRRP announcement period, readmissions declined significantly for those aged 40–64 years for AMI (p < 0.0001) and HF (p = 0.003). Readmissions decreased significantly in the post-HRRP period for those aged 40–64 years at a slower rate for AMI (p = 0.003) and HF (p = 0.05). Readmission rates among younger patients (18–64 years) varied within all four targeted conditions in HRRP announcement and post-HRRP periods. Adjusted models showed a significantly higher readmission cost in those readmitted within 30 days among younger and older populations for AMI (p < 0.0001), HF (p < 0.0001), pneumonia (p < 0.0001), and AECOPD (p < 0.0001). Conclusion Readmissions for targeted conditions decreased in the U.S. during the enactment of the HRRP policy and younger age groups (< 65 years) not targeted by the policy saw a mixed effect. Healthcare expenditures in younger and older populations were significantly higher for early readmissions with all targeted conditions. Further research is necessary evaluating total healthcare utilization including emergency department visits, observation units, and hospital readmissions in order to better understand the extent of the HRRP on U.S. healthcare. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06399-z.
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Affiliation(s)
- Chi-Hua Lu
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, 316 Pharmacy Building, Buffalo, NY, USA
| | - Collin M Clark
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, 316 Pharmacy Building, Buffalo, NY, USA
| | - Ryan Tober
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, 316 Pharmacy Building, Buffalo, NY, USA
| | - Meghan Allen
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, 316 Pharmacy Building, Buffalo, NY, USA
| | - Walter Gibson
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, 316 Pharmacy Building, Buffalo, NY, USA
| | - Edward M Bednarczyk
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, 316 Pharmacy Building, Buffalo, NY, USA
| | - Christopher J Daly
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, 316 Pharmacy Building, Buffalo, NY, USA
| | - David M Jacobs
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, 316 Pharmacy Building, Buffalo, NY, USA.
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Morgenthaler TI, Lim K, Larson M, Helfinstine K, Homan J, Schwarz R, Dankbar G. A Practice Redesign Collaborative for Reducing Hospital Readmission for Chronic Obstructive Pulmonary Disease in an Affiliated Network of Health Care Organizations. Jt Comm J Qual Patient Saf 2021; 47:412-421. [PMID: 33910766 DOI: 10.1016/j.jcjq.2021.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 03/03/2021] [Accepted: 03/23/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Patients discharged following admissions for acute exacerbations of chronic obstructive pulmonary disease (AE-COPD) frequently require unplanned readmissions, increasing costs and morbidity for thousands of patients suffering from COPD. The Hospital Readmissions Reduction Program provided financial incentives to reduce 30-day readmissions for AE-COPD, but although risk factors for readmission are known, few evidence-based interventions achieve this goal. Members of the Mayo Clinic Care Network (MCCN) formed a collaborative to seek ways to reduce 30-day readmission for patients admitted with AE-COPD. METHODS Seventeen MCCN organizations participated in an improvement collaborative in 2016 and 2017. Mayo Clinic subject matter experts shared improvement webinars, protocols, and educational materials related to AE-COPD and delivered individualized coaching to facilitate improvement at each site over a six-month engagement. Among other recommended interventions, organizations worked to increase the proportion of COPD patients who had a standardized disease severity staging during admission, inhaler appropriateness evaluations, a COPD treatment action plan, and clinical contact at < 48 hours and 10 ± 4 days postdischarge. RESULTS Same-hospital readmission rates improved from 17.7% ± 3.6 to 14.5% ± 4.0 (weighted difference -4.38, p = 0.008, paired t-test). In addition, participating teams stated that the collaborative framework helped them develop strategies that improved patient care and organizational capacity for improvement in other domains. CONCLUSION The collaborative framework, beginning with education delivered in person and via webinars, combined with telephonically delivered coaching and knowledge sharing, assisted most members to improve care. Fourteen of 17 participating sites experienced a reduced AE-COPD readmission rate.
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Spece LJ, Donovan LM, Griffith MF, Keller T, Feemster LC, Smith NL, Au DH. Initiating Low-Value Inhaled Corticosteroids in an Inception Cohort with Chronic Obstructive Pulmonary Disease. Ann Am Thorac Soc 2020; 17:589-95. [PMID: 31899652 DOI: 10.1513/AnnalsATS.201911-854OC] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Rationale: Decreasing medication overuse represents an opportunity to avoid harm and costs in the era of value-based purchasing. Studies of inhaled corticosteroids (ICS) overuse in chronic obstructive pulmonary disease (COPD) have examined prevalent use. Understanding initiation of low-value ICS among complex patients with COPD may help shape deadoption efforts.Objectives: Examine ICS initiation among a cohort with low exacerbation risk COPD and test for associations with markers of patient and health system complexity.Methods: Between 2012 and 2016, we identified veterans with COPD from 21 centers. Our primary outcome was first prescription of ICS. We used the care assessment needs (CAN) score to assess patient-level complexity as the primary exposure. We used a time-to-event model with time-varying exposures over 1-year follow-up. We tested for effect modification using selected measures of health system complexity.Results: We identified 8,497 patients with COPD without an indication for ICS and did not have baseline use (inception cohort). Follow-up time was four quarters. Patient complexity by a continuous CAN score was associated with new dispensing of ICS (hazard ratio = 1.17 per 10-unit change; 95% confidence interval = 1.13-1.21). This association demonstrated a dose-response when examining quartiles of CAN score. Markers of health system complexity did not modify the association between patient complexity and first use of low-value ICS.Conclusions: Patient complexity may represent a symptom burden that clinicians are attempting to mitigate by initiating ICS. Lack of effect modification by health system complexity may reflect the paucity of structural support and low prioritization for COPD care.
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Myers LC, Faridi MK, Hasegawa K, Hanania NA, Camargo CA Jr. The Hospital Readmissions Reduction Program and Readmissions for Chronic Obstructive Pulmonary Disease, 2006-2015. Ann Am Thorac Soc 2020; 17:450-6. [PMID: 31860333 DOI: 10.1513/AnnalsATS.201909-672OC] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Rationale: In October 2012, the initial phase of the Hospital Readmission Reduction Program imposed financial penalties on hospitals with higher-than-expected risk-adjusted 30-day readmission rates for Medicare beneficiaries with congestive heart failure, myocardial infarction, and pneumonia. We hypothesized that these penalties may also be associated with decreased readmissions for chronic obstructive pulmonary disease (COPD) in the general population before COPD became a target condition (October 2014).Objectives: To determine if implementation of the initial financial penalties for other conditions was associated with a decrease in hospital readmissions for COPD.Methods: We used population-level data to examine patients readmitted for any reason or for COPD within 30 days after an initial hospitalization for COPD. The data source was seven states in the State Inpatient Database. The preimplementation period included calendar years 2006 to 2012. The postimplementation period included 2013 to 2015. Using interrupted time series, the level change was examined, which reflected the difference between the expected and actual readmission rates in 2013. The difference in slopes between the pre- and postimplementation periods was also examined.Results: We identified 805,764 hospitalizations for COPD from 904 hospitals. Overall, 26% of patients had primary insurance other than Medicare. After the intervention, patients had lower rates of all-cause 30-day readmissions (level change, -0.93%; 95% confidence interval [CI], -1.44% to -0.43%; P = 0.004), which was driven by fewer early readmissions (0-7 d). The postimplementation slope became positive; the difference in slopes was 0.39% (95% CI, 0.28% to 0.50%; P < 0.001). Patients also had lower rates of COPD-related readmissions (level decrease, -0.52%; 95% CI, -0.93% to -0.12%; P = 0.02), which was due to decreases in both early and late (8-30 d) readmissions. The postimplementation slope was negative; the difference in slopes was -0.21% (95% CI, -0.35% to -0.07%; P = 0.009).Conclusions: In patients with COPD and any insurance status, there was an association between the initial phase of the Hospital Readmission Reduction Program and a decrease in both all-cause and COPD-related readmissions even before COPD became a target diagnosis. The large amount of money at risk to hospitals likely resulted in broad behavioral change. Future research is needed to test which levers can effectively reduce readmission rates for COPD.
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Press VG, Myers LC, Feemster LC. Preventing COPD Readmissions Under the Hospital Readmissions Reduction Program: How Far Have We Come? Chest 2021; 159:996-1006. [PMID: 33065106 PMCID: PMC8501005 DOI: 10.1016/j.chest.2020.10.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 09/10/2020] [Accepted: 10/01/2020] [Indexed: 01/06/2023] Open
Abstract
The Hospital Readmissions Reduction Program (HRRP) was developed and implemented by the Centers for Medicare & Medicaid Services to curb the rate of 30-day hospital readmissions for certain common, high-impact conditions. In October 2014, COPD became a target condition for which hospitals were penalized for excess readmissions. The appropriateness, utility, and potential unintended consequences of the metric have been a topic of debate since it was first enacted. Nevertheless, there is evidence that hospital policies broadly implemented in response to the HRRP may have been responsible for reducing the rate of readmissions following COPD hospitalizations even before it was added as a target condition. Since the addition of the COPD condition to the HRRP, several predictive models have been developed to predict COPD survival and readmissions, with the intention of identifying modifiable risk factors. A number of interventions have also been studied, with mixed results. Bundled care interventions using the electronic health record and patient education interventions for inhaler education have been shown to reduce readmissions, whereas pulmonary rehabilitation, follow-up visits, and self-management programs have not been consistently shown to do the same. Through this program, COPD has become recognized as a public health priority. However, 5 years after COPD became a target condition for HRRP, there continues to be no single intervention that reliably prevents readmissions in this patient population. Further research is needed to understand the long-term effects of the policy, the role of competing risks in measuring quality, the optimal postdischarge care for patients with COPD, and the integrated use of predictive modeling and advanced technologies to prevent COPD readmissions.
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Affiliation(s)
- Valerie G Press
- Section of General Internal Medicine University of Chicago Medicine.
| | - Laura C Myers
- Divisions of Research and Pulmonary/Critical Care Medicine, Kaiser Permanente Northern California
| | - Laura C Feemster
- Division of Pulmonary, Critical Care, and Sleep Medicine, VA Puget Sound Health Care System
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Althoff MD, Holguin F, Yang F, Grunwald GK, Moss M, Vandivier RW, Ho PM, Kiser TH, Burnham EL. Noninvasive Ventilation Use in Critically Ill Patients with Acute Asthma Exacerbations. Am J Respir Crit Care Med 2020; 202:1520-1530. [PMID: 32663410 PMCID: PMC7706169 DOI: 10.1164/rccm.201910-2021oc] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Accepted: 07/14/2020] [Indexed: 12/21/2022] Open
Abstract
Rationale: Noninvasive ventilation decreases the need for invasive mechanical ventilation and mortality among patients with chronic obstructive pulmonary disease but has not been well studied in asthma.Objectives: To assess the association between noninvasive ventilation and subsequent need for invasive mechanical ventilation and in-hospital mortality among patients admitted with asthma exacerbation to the ICU.Methods: We performed a retrospective cohort study using administrative data collected during 2010-2017 from 682 hospitals in the United States. Outcomes included receipt of invasive mechanical ventilation and in-hospital mortality. Generalized estimating equations, propensity-matched models, and marginal structural models were used to assess the association between noninvasive ventilation and outcomes.Measurements and Main Results: The study population included 53,654 participants with asthma exacerbation. During the study period, 13,540 patients received noninvasive ventilation (25.2%; 95% confidence interval [CI], 24.9-25.6%), 14,498 underwent invasive mechanical ventilation (27.0%; 95% CI, 26.7-27.4%), and 1,291 died (2.4%; 95% CI, 2.3-2.5%). Among those receiving noninvasive ventilation, 3,013 patients (22.3%; 95% CI, 21.6-23.0%) required invasive mechanical ventilation after first receiving noninvasive ventilation, 136 of whom died (4.5%; 95% CI, 3.8-5.3%). Across all models, the use of noninvasive ventilation was associated with a lower odds of receiving invasive mechanical ventilation (adjusted generalized estimating equation odds ratio, 0.36; 95% CI, 0.32-0.40) and in-hospital mortality (odds ratio, 0.48; 95% CI 0.40-0.58). Those who received noninvasive ventilation before invasive mechanical ventilation were more likely to have comorbid pneumonia and severe sepsis.Conclusions: Noninvasive ventilation use during asthma exacerbation was associated with improved outcomes but should be used cautiously with acute comorbid conditions.
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Affiliation(s)
- Meghan D. Althoff
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Aurora, Colorado
| | - Fernando Holguin
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Aurora, Colorado
| | - Fan Yang
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado
| | - Gary K. Grunwald
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Aurora, Colorado
| | - R. William Vandivier
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Aurora, Colorado
| | - P. Michael Ho
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado
- Division of Cardiology, VA Eastern Colorado Health Care System, Aurora, Colorado; and
| | - Tyree H. Kiser
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado
| | - Ellen L. Burnham
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Aurora, Colorado
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Echevarria C, Steer J, Bourke SC. Coding of COPD Exacerbations and the Implications on Clinical Practice, Audit and Research. COPD 2020; 17:706-710. [PMID: 33169617 DOI: 10.1080/15412555.2020.1841745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
International Classification of Disease 10 (ICD-10) codes record hospital admissions. We aimed to measure the accuracy of COPD exacerbation (ECOPD) codes and examine coding practices for COPD exacerbation.Prospective screening and ICD-10 codes were used to identify potential ECOPD within the DECAF internal validation cohort. Two coding searches were performed. The first search identified patients with an ECOPD discharge code, and a second, broad search was developed to identify all clinically confirmed ECOPD.717 of 1,122 (64%) patients with an ECOPD code had confirmed ECOPD. Common reasons for misclassification in the 405 patients who did not have an ECOPD included: lack of obstructive spirometry to diagnose COPD; and hospital admission due to progressive malignancy, asthma or cardiovascular disease. The broad search identified an additional 297 patients with ECOPD missed by the ECOPD codes. The vast majority of this group had pneumonia complicating ECOPD.ECOPD codes are insufficiently reliable to identify patients with clinically confirmed ECOPD for the purposes of audit or research. Search strategies should include pneumonia codes, specialist review of medical notes and spirometry confirmation of COPD.
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Affiliation(s)
- C Echevarria
- Department of Respiratory, Royal Victoria Infirmary, Newcastle Upon Tyne, UK.,Translational and Clinical Research Institute, Medical School, Newcastle University, Newcastle Upon Tyne, UK
| | - J Steer
- Translational and Clinical Research Institute, Medical School, Newcastle University, Newcastle Upon Tyne, UK.,Department of Respiratory, North Tyneside General Hospital, Newcastle Upon Tyne, UK
| | - S C Bourke
- Translational and Clinical Research Institute, Medical School, Newcastle University, Newcastle Upon Tyne, UK.,Department of Respiratory, North Tyneside General Hospital, Newcastle Upon Tyne, UK
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Hegewald MJ, Horne BD, Trudo F, Kreindler JL, Chung Y, Rea S, Blagev DP. Blood Eosinophil Count and Hospital Readmission in Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease. Int J Chron Obstruct Pulmon Dis 2020; 15:2629-2641. [PMID: 33122901 PMCID: PMC7591040 DOI: 10.2147/copd.s251115] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 10/07/2020] [Indexed: 01/08/2023] Open
Abstract
Purpose This retrospective, observational cohort study investigated the association of blood eosinophil counts within 1 week of hospitalization for acute exacerbation of COPD (AECOPD) with subsequent risk of all-cause and COPD-related readmission from a large integrated health system. Patients and Methods Electronic medical records were extracted for index hospitalization for AECOPD at all Intermountain Healthcare hospitals. The primary outcome was the relationship of blood eosinophil count to 30-day all-cause readmission; secondary outcomes were 60-day, 90-day, and 12-month all-cause readmission, COPD-related readmission, and empiric derivation of the eosinophil count with the highest area under the curve (AUC) for predicting 30-day all-cause readmission. Results Of 2445 included patients, 1935 (79%) had a blood eosinophil count <300 cells/µL and 510 (21%) had a count ≥300 cells/µL. Using a 300-cells/μL threshold, there was no significant difference between high and low eosinophil groups in 30-day (odds ratio [OR]=1.05, 95% confidence interval [CI]=0.75–1.47) or 60-day (OR=1.15, 95% CI=0.88–1.51) all-cause readmissions. However, patients with greater (versus lesser) eosinophil counts had increased 90-day and 12-month all-cause readmissions (OR=1.35, 95% CI=1.06–1.72, and OR=1.32, 95% CI=1.07–1.62). COPD-related readmission rates were significantly greater for patients with greater (versus lesser) eosinophil counts at 30, 60, and 90 days and 12 months (OR range=1.52–1.97). A total of 70 cells/µL had the most discriminatory power to predict 30-day all-cause readmission (highest AUC). Conclusion Eosinophil counts in patients with COPD were not associated with a difference in 30-day all-cause readmissions. However, greater eosinophil counts were associated with increased risk of all-cause readmission at 90 days and 12 months and COPD-related readmission at 30, 60, and 90 days and 12 months. Patients with eosinophils <70 cells/μL had the lowest risk for 30-day all-cause readmission. Blood eosinophils in patients hospitalized with AECOPD may be a useful biomarker for the risk of hospital readmission.
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Affiliation(s)
- Matthew J Hegewald
- Pulmonary and Critical Care Medicine Division, Intermountain Medical Center, Murray, UT, USA.,Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT, USA
| | - Benjamin D Horne
- Intermountain Heart Institute at Intermountain Healthcare, Salt Lake City, UT, USA.,Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Frank Trudo
- Health Economics Outcomes Research, AstraZeneca, Wilmington, DE, USA
| | - James L Kreindler
- Health Economics Outcomes Research, AstraZeneca, Wilmington, DE, USA
| | - Yen Chung
- Health Economics Outcomes Research, AstraZeneca, Wilmington, DE, USA
| | - Susan Rea
- Enterprise Analytics, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Denitza P Blagev
- Pulmonary and Critical Care Medicine Division, Intermountain Medical Center, Murray, UT, USA.,Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT, USA
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Stanford RH, Engel-Nitz NM, Bancroft T, Essoi B. The Identification and Cost of Acute Chronic Obstructive Pulmonary Disease Exacerbations in a United States Population Healthcare Claims Database. COPD 2020; 17:499-508. [PMID: 32962447 DOI: 10.1080/15412555.2020.1817357] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Almost half of chronic obstructive pulmonary disease (COPD) exacerbations are estimated to be inaccurately reported by patients, inconsistently recorded in medical records, or not measured due to coding errors inherent to administrative claims. This retrospective observational study aimed to develop an algorithm capable of detecting acute COPD exacerbations (AECOPD) in healthcare claims and estimate costs associated with AECOPD over a 12-month period. Commercial and Medicare Advantage healthcare plan members (≥40 years old) with evidence of COPD were identified from US healthcare-claims database. To refine the algorithm detecting AECOPD in claims data, sensitivity and positive-predictive value calculations were performed to compare AECOPD identification in healthcare claims versus medical charts. Analyses were also performed to examine total exacerbation-related costs for events identified with the new claims algorithm plus events missed. The final algorithm had a sensitivity of 84.9%, with a positive-predictive value of 67.5%. Medical records were abstracted for 402 patients. In the overall sample of healthcare claims (n = 243,998), the algorithm detected ≥1 AECOPD event in 61.3% of patients. The mean cost per patient during an AECOPD episode, identified by the final algorithm, was USD 6,760 (n = 301), with an incremental average cost of USD 607 (n = 122) to 'unobserved' episodes (not reported in claims data) among the chart sample. After multivariate modeling, predicted yearly exacerbation costs translated to USD 1.12 billion per 100,000 patients (USD 12,000 per patient), with 35.76 million associated with unobserved exacerbations. While the final algorithm warrants further validation and study, these findings highlight unobserved AECOPD and their economic burden.
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Affiliation(s)
- Richard H Stanford
- US Value Evidence and Outcomes, GlaxoSmithKline plc, Research Triangle Park, NC, USA
| | | | | | - Breanna Essoi
- Health Economics and Outcomes Research, Optum, MN, USA
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Wei MY, Luster JE, Chan CL, Min L. Comprehensive review of ICD-9 code accuracies to measure multimorbidity in administrative data. BMC Health Serv Res 2020; 20:489. [PMID: 32487087 PMCID: PMC7268621 DOI: 10.1186/s12913-020-05207-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 04/13/2020] [Indexed: 12/04/2022] Open
Abstract
Background Quantifying the burden of multimorbidity for healthcare research using administrative data has been constrained. Existing measures incompletely capture chronic conditions of relevance and are narrowly focused on risk-adjustment for mortality, healthcare cost or utilization. Moreover, the measures have not undergone a rigorous review for how accurately the components, specifically the International Classification of Diseases, Ninth Revision (ICD-9) codes, represent the chronic conditions that comprise the measures. We performed a comprehensive, structured literature review of research studies on the accuracy of ICD-9 codes validated using external sources across an inventory of 81 chronic conditions. The conditions as a weighted measure set have previously been demonstrated to impact not only mortality but also physical and mental health-related quality of life. Methods For each of 81 conditions we performed a structured literature search with the goal to identify 1) studies that externally validate ICD-9 codes mapped to each chronic condition against an external source of data, and 2) the accuracy of ICD-9 codes reported in the identified validation studies. The primary measure of accuracy was the positive predictive value (PPV). We also reported negative predictive value (NPV), sensitivity, specificity, and kappa statistics when available. We searched PubMed and Google Scholar for studies published before June 2019. Results We identified studies with validation statistics of ICD-9 codes for 51 (64%) of 81 conditions. Most of the studies (47/51 or 92%) used medical chart review as the external reference standard. Of the validated using medical chart review, the median (range) of mean PPVs was 85% (39–100%) and NPVs was 91% (41–100%). Most conditions had at least one validation study reporting PPV ≥70%. Conclusions To help facilitate the use of patient-centered measures of multimorbidity in administrative data, this review provides the accuracy of ICD-9 codes for chronic conditions that impact a universally valued patient-centered outcome: health-related quality of life. These findings will assist health services studies that measure chronic disease burden and risk-adjust for comorbidity and multimorbidity using patient-centered outcomes in administrative data.
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Affiliation(s)
- Melissa Y Wei
- Division of General Medicine, Department of Internal Medicine, University of Michigan, 2800 Plymouth Road, Bldg 16, Rm 430W, Ann Arbor, MI, 48109, USA. .,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.
| | - Jamie E Luster
- Division of General Medicine, Department of Internal Medicine, University of Michigan, 2800 Plymouth Road, Bldg 16, Rm 430W, Ann Arbor, MI, 48109, USA
| | - Chiao-Li Chan
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Lillian Min
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.,VA Ann Arbor Healthcare System and the Geriatric Research Education Clinical Center (GRECC), Ann Arbor, MI, USA
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Joo J, Hobbs BD, Cho MH, Himes BE. Trait Insights Gained by Comparing Genome-Wide Association Study Results using Different Chronic Obstructive Pulmonary Disease Definitions. AMIA Jt Summits Transl Sci Proc 2020; 2020:278-287. [PMID: 32477647 PMCID: PMC7233028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Biobanks have facilitated the conduct of large-scale genomics studies, but they are challenged by the difficulty of validating some phenotypes, particularly for complex traits that represent heterogeneous groups ofpatients. The guideline definition of COPD, based on objective spirometry measures, has been preferred in genome-wide association studies (GWAS) conducted with epidemiological cohorts, but spirometry measures are seldom available for biobank participants. Defining COPD based on International Classification of Disease (ICD) codes or self-reported measures is highly feasible in biobanks, but it remains unclear whether the misclassification inherent in these definitions prevent the discovery of genetic variants that contribute to COPD. We found that while there was poor agreement in classification of UK Biobank participants as having COPD based on ICD diagnosis codes, self-reported doctor diagnosis or spirometry measures, contrasting GWAS results for these definitions provided insights into what patient characteristics each trait may capture.
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Affiliation(s)
- Jaehyun Joo
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Brian D Hobbs
- Channing Division of Network Medicine and Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Michael H Cho
- Channing Division of Network Medicine and Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Blanca E Himes
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Stefan MS, Pekow PS, Shea CM, Hughes AM, Hill NS, Steingrub JS, Lindenauer PK. Protocol for two-arm pragmatic cluster randomized hybrid implementation-effectiveness trial comparing two education strategies for improving the uptake of noninvasive ventilation in patients with severe COPD exacerbation. Implement Sci Commun 2020; 1:46. [PMID: 32435762 PMCID: PMC7223919 DOI: 10.1186/s43058-020-00028-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 03/23/2020] [Indexed: 11/30/2022] Open
Abstract
Background COPD is the fourth leading cause of death in the US, and COPD exacerbations result in approximately 700,000 hospitalizations annually. Patients with acute respiratory failure due to severe COPD exacerbation are treated with invasive (IMV) or noninvasive mechanical ventilation (NIV). Although IMV reverses hypercapnia/hypoxia, it causes significant morbidity and mortality. There is strong evidence that patients treated with NIV have better outcomes, and NIV is recommended as first line therapy in these patients. Yet, several studies have demonstrated substantial variation in the use of NIV across hospitals, leading to preventable morbidity and mortality. Through a series of mixed-methods studies, we have found that successful implementation of NIV requires physicians, respiratory therapists (RTs), and nurses to communicate and collaborate effectively, suggesting that efforts to increase the use of NIV in COPD need to account for the complex and interdisciplinary nature of NIV delivery and the need for team coordination. Therefore, we propose to compare two educational strategies: online education (OLE) and interprofessional education (IPE) which targets complex team-based care in NIV delivery. Methods and design Twenty hospitals with low baseline rates of NIV use will be randomized to either the OLE or IPE study arm. The primary outcome of the trial is change in the hospital rate of NIV use among patients with COPD requiring ventilatory support. In aim 1, we will compare the uptake change over time of NIV use among patients with COPD in hospitals enrolled in the two arms. In aim 2, we will explore mediators’ role (respiratory therapist autonomy and team functionality) on the relationship between the implementation strategies and implementation effectiveness. Finally, in aim 3, through interviews with providers, we will assess acceptability and feasibility of the educational training. Discussions This study will be among the first to carefully test the impact of IPE in the inpatient setting. This work promises to change practice by offering approaches to facilitate greater uptake of NIV and may generalize to other interventions directed to seriously-ill patients. Trial registration Name of registry: ClinicalTrials.gov Trial registration number: NCT04206735 Date of Registration: December 20, 2019
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Affiliation(s)
- Mihaela S Stefan
- 1Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield, MA USA.,2Department of Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA USA
| | - Penelope S Pekow
- 1Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield, MA USA.,3School of Public Health and Health Sciences, University of Massachusetts, Amherst, MA USA
| | - Christopher M Shea
- 4Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Chapel Hill, NC USA
| | - Ashley M Hughes
- 5College of Applied Health Science, University of Illinois at Chicago, Chicago, IL USA
| | - Nicholas S Hill
- 6Division of Pulmonary and Critical Care Medicine, Tufts University School of Medicine, Boston, MA USA
| | - Jay S Steingrub
- 7Division of Pulmonary and Critical Care, Department of Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA USA
| | - Peter K Lindenauer
- 1Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield, MA USA.,2Department of Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA USA.,8Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA USA
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Rinne ST, Press VG. Moving the Bar on Chronic Obstructive Pulmonary Disease Readmissions before and after the Hospital Readmission Reduction Program: Myth or Reality? Ann Am Thorac Soc 2020; 17:423-5. [DOI: 10.1513/annalsats.202001-010ed] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Buhr RG, Jackson NJ, Dubinett SM, Kominski GF, Mangione CM, Ong MK. Factors Associated with Differential Readmission Diagnoses Following Acute Exacerbations of Chronic Obstructive Pulmonary Disease. J Hosp Med 2020; 15:219-227. [PMID: 32118572 PMCID: PMC7153488 DOI: 10.12788/jhm.3367] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Readmissions after exacerbations of chronic obstructive pulmonary disease (COPD) are penalized under the Hospital Readmissions Reduction Program (HRRP). Understanding attributable diagnoses at readmission would improve readmission reduction strategies. OBJECTIVES Determine factors that portend 30-day readmissions attributable to COPD versus non-COPD diagnoses among patients discharged following COPD exacerbations. DESIGN, SETTING, AND PARTICIPANTS We analyzed COPD discharges in the Nationwide Readmissions Database from 2010 to 2016 using inclusion and readmission definitions in HRRP. MAIN OUTCOMES AND MEASURES We evaluated readmission odds for COPD versus non-COPD returns using a multilevel, multinomial logistic regression model. Patient-level covariates included age, sex, community characteristics, payer, discharge disposition, and Elixhauser Comorbidity Index. Hospital-level covariates included hospital ownership, teaching status, volume of annual discharges, and proportion of Medicaid patients. RESULTS Of 1,622,983 (a weighted effective sample of 3,743,164) eligible COPD hospitalizations, 17.25% were readmitted within 30 days (7.69% for COPD and 9.56% for other diagnoses). Sepsis, heart failure, and respiratory infections were the most common non-COPD return diagnoses. Patients readmitted for COPD were younger with fewer comorbidities than patients readmitted for non-COPD. COPD returns were more prevalent the first two days after discharge than non-COPD returns. Comorbidity was a stronger driver for non-COPD (odds ratio [OR] 1.19) than COPD (OR 1.04) readmissions. CONCLUSION Thirty-day readmissions following COPD exacerbations are common, and 55% of them are attributable to non-COPD diagnoses at the time of return. Higher burden of comorbidity is observed among non-COPD than COPD rehospitalizations. Readmission reduction efforts should focus intensively on factors beyond COPD disease management to reduce readmissions considerably by aggressively attempting to mitigate comorbid conditions.
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Affiliation(s)
- Russell G Buhr
- Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
- Department of Health Policy and Management, Jonathan and Karin Fielding School of Public Health, University of California, Los Angeles, California
- Medical Service, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California
- Corresponding Author: Russell G. Buhr, MD, PhD; E-mail: ; Telephone: 310-267-2614; Twitter: @rgbMDPhD
| | - Nicholas J Jackson
- Department of Medicine Statistics Core, University of California, Los Angeles, California
| | - Steven M Dubinett
- Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
- Medical Service, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California
| | - Gerald F Kominski
- Department of Health Policy and Management, Jonathan and Karin Fielding School of Public Health, University of California, Los Angeles, California
- Center for Health Policy Research, Jonathan and Karin Fielding School of Public Health, University of California, Los Angeles, California
| | - Carol M Mangione
- Department of Health Policy and Management, Jonathan and Karin Fielding School of Public Health, University of California, Los Angeles, California
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Michael K Ong
- Department of Health Policy and Management, Jonathan and Karin Fielding School of Public Health, University of California, Los Angeles, California
- Medical Service, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California
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Rong Y, Bentley JP, McGwin G, Yang Y, Banahan BF, Noble SL, Kirby T, Ramachandran S. Association Between Transient Opioid Use and Short-Term Respiratory Exacerbation Among Adults With Chronic Obstructive Pulmonary Disease: A Case-Crossover Study. Am J Epidemiol 2019; 188:1970-1976. [PMID: 31361012 DOI: 10.1093/aje/kwz169] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 07/13/2019] [Accepted: 07/15/2019] [Indexed: 11/14/2022] Open
Abstract
The association of historical opioid use with health care use and death among patients with chronic obstructive pulmonary disease (COPD) has been tested. Using Mississippi Medicaid data, we examined the association of transient or short-term opioid use and acute respiratory exacerbations among adults with COPD. We used a case-crossover design and 2013-2017 Mississippi Medicaid administrative claims data. A total of 1,972 qualifying exacerbation events occurred in 1,354 beneficiaries. The frequency and dose of opioid exposure in the 7 days before the exacerbation were examined and compared with the opioid exposure in 10 control windows, each 7 days long, before the exacerbation. Adjusted odds ratios were estimated using conditional logistic regression models to estimate the risk of opioid use on exacerbations after accounting for use of bronchodilators, corticosteroids, benzodiazepines, and β-blockers. Overall, opioid exposure in the 7 days before an exacerbation was significantly associated with acute respiratory exacerbation (odds ratio = 1.81; 95% confidence interval: 1.60, 2.05). Each 25-mg increase in morphine equivalent daily dose was associated with an 11.2% increase in the odds of an acute respiratory exacerbation (odds ratio = 1.11; 95% confidence interval: 1.04, 1.20). Transient use of opioids was significantly associated with acute respiratory exacerbation of COPD.
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de Miguel-Diez J, Jiménez-García R, Hernández-Barrera V, Puente-Maestu L, Girón-Matute WI, de Miguel-Yanes JM, Méndez-Bailón M, Villanueva-Orbaiz R, Albaladejo-Vicente R, López-de-Andrés A. Trends in the Use and Outcomes of Mechanical Ventilation among Patients Hospitalized with Acute Exacerbations of COPD in Spain, 2001 to 2015. J Clin Med 2019; 8:E1621. [PMID: 31590235 DOI: 10.3390/jcm8101621] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 09/25/2019] [Accepted: 09/26/2019] [Indexed: 12/05/2022] Open
Abstract
(1) Background: We examine trends (2001–2015) in the use of non-invasive ventilation (NIV) and invasive mechanical ventilation (IMV) among patients hospitalized for acute exacerbation of chronic obstructive pulmonary disease (AE-COPD). (2) Methods: Observational retrospective epidemiological study, using the Spanish National Hospital Discharge Database. (3) Results: We included 1,431,935 hospitalizations (aged ≥40 years) with an AE-COPD. NIV use increased significantly, from 1.82% in 2001–2003 to 8.52% in 2013–2015, while IMV utilization decreased significantly, from 1.39% in 2001–2003 to 0.67% in 2013–2015. The use of NIV + invasive mechanical ventilation (IMV) rose significantly over time (from 0.17% to 0.42%). Despite the worsening of clinical profile of patients, length of stay decreased significantly over time in all types of ventilation. Patients who received only IMV had the highest in-hospital mortality (IHM) (32.63%). IHM decreased significantly in patients with NIV + IMV, but it remained stable in those receiving isolated NIV and isolated IMV. Factors associated with use of any type of ventilatory support included female sex, lower age, and higher comorbidity. (4) Conclusions: We found an increase in NIV use and a decline in IMV utilization to treat AE-COPD among hospitalized patients. The IHM decreased significantly over time in patients who received NIV + IMV, but it remained stable in patients who received NIV or IMV in isolation.
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Baillargeon J, Singh G, Kuo YF, Raji MA, Westra J, Sharma G. Association of Opioid and Benzodiazepine Use with Adverse Respiratory Events in Older Adults with Chronic Obstructive Pulmonary Disease. Ann Am Thorac Soc 2019; 16:1245-1251. [PMID: 31104504 PMCID: PMC6812171 DOI: 10.1513/annalsats.201901-024oc] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 05/15/2019] [Indexed: 12/31/2022] Open
Abstract
Rationale: Older adults with chronic obstructive pulmonary disease (COPD) are at substantially increased risk for medication-related adverse events. Two frequently prescribed classes of drugs that pose a particular risk to this patient group are opioids and benzodiazepines. Research on this topic has yielded conflicting findings.Objectives: The purpose of this study was to examine, among older adults with COPD, whether: 1) independent or concurrent use of opioid and benzodiazepine medications was associated with hospitalizations for respiratory events, and 2) this association was exacerbated by the presence of obstructive sleep apnea (OSA).Methods: We conducted a case-control study of Medicare beneficiaries aged ≥66 years, who were diagnosed with COPD in 2013, using the 5% national Medicare database. Cases (n = 3,232) were defined as patients hospitalized for a primary COPD-related respiratory diagnosis in 2014 and were matched with up to two control subjects (n = 6,247) on index date, age, sex, socioeconomic status, comorbidity, presence of OSA, COPD medication, and COPD complexity.Results: In comparison to the referent (no opioid or benzodiazepine use), opioid use alone (adjusted odds ratio [aOR], 1.73; 95% confidence interval [CI], 1.52-1.97), benzodiazepine use alone (aOR, 1.42; 95% CI, 1.21-1.66), and concurrent opioid/ benzodiazepine use (aOR, 2.32; 95% CI, 1.94-2.77) in the 30 days before the event/index date were all associated with an increased risk of hospitalization for a respiratory condition. Risk of hospitalization was higher with concurrent opioid and benzodiazepine use when compared with use of either medication alone. There was no statistically significant interaction between OSA and either of the drugs, alone or in combination. However, the adverse respiratory effects of concurrent opioid and benzodiazepine use were increased in patients with a high degree of COPD complexity. All of the above findings persisted using exposure windows that extended to 60 and 90 days before the event/index date.Conclusions: Among older adults with COPD, use of opioid and benzodiazepine medications alone or in combination were associated with increased adverse respiratory events. The adverse effects of these medications were not exacerbated in patients with COPD-OSA overlap syndrome. However, the adverse impact of dual opioid and benzodiazepine was greater in patients with high-complexity COPD.
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Affiliation(s)
- Jacques Baillargeon
- Department of Preventive Medicine and Community Health
- Sealy Center on Aging, and
| | - Gurinder Singh
- Internal Medicine Residency Program, San Joaquin General Hospital, French Camp, California
| | - Yong-Fang Kuo
- Department of Preventive Medicine and Community Health
- Sealy Center on Aging, and
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas; and
| | - Mukaila A. Raji
- Sealy Center on Aging, and
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas; and
| | - Jordan Westra
- Department of Preventive Medicine and Community Health
| | - Gulshan Sharma
- Sealy Center on Aging, and
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas; and
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de-Miguel-Díez J, López-de-Andrés A, Hernández-Barrera V, De Miguel-Yanes JM, Méndez-Bailón M, Muñoz-Rivas N, Jiménez-García R. Trends, characteristics, in-hospital outcomes and mortality in surgical mitral valve replacement among patients with and without COPD in Spain (2001-2015). PLoS One 2019; 14:e0221263. [PMID: 31425536 PMCID: PMC6699799 DOI: 10.1371/journal.pone.0221263] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 08/04/2019] [Indexed: 12/20/2022] Open
Abstract
PURPOSE We examined trends, characteristics and in-hospital outcomes in mechanical and bioprosthetic surgical mitral valve replacement (SMVR) among patients with and without chronic obstructive pulmonary disease (COPD) in Spain from 2001 to 2015. We also identified factors associated with in-hospital mortality (IHM) in both groups of patients according to the implanted valve type. METHODS We analyzed data from the Spanish National Hospital Discharge Database for patients aged 40 years or over. We selected admissions of patients whose medical procedures included SMVR. We grouped hospitalizations by COPD status. RESULTS Over 43,024 patients identified, 83.63% underwent mechanical mitral valve replacement and 16.37% bioprosthetic valve (6.71% and 7.78% with COPD, respectively). The incidence of SMVR decreased for mechanical valves and increased for bioprosthetic valves over time in both groups of patients. The incidence of SMVR admissions was lower among COPD patients than in those without COPD, both for mechanical and bioprosthetic valves. IHM decreased significantly over time, regardless of the type of valve, in both groups of patients. COPD was associated with a significant increase in IHM, but only among patients who underwent bioprosthetic SMVR (OR 1.32, 95% CI 1.01-1.73). CONCLUSIONS The incidence of mechanical SMVR decreased while that of bioprosthetic SMVR increased over time in both groups of patients. COPD patients were less surgically operated than non-COPD patients for both valve types. In COPD patients, bioprosthetic SMVR was proportionally more used than mechanical SMVR. Mortality decreased over time for both valve types in patients with and without COPD. COPD increased in-hospital mortality among patients undergoing a biological SMVR.
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Affiliation(s)
- Javier de-Miguel-Díez
- Respiratory Department, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid (UCM), Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - Ana López-de-Andrés
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Rey Juan Carlos University, Alcorcón, Madrid, Spain
- * E-mail:
| | - Valentín Hernández-Barrera
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Rey Juan Carlos University, Alcorcón, Madrid, Spain
| | - José M. De Miguel-Yanes
- Internal Medicine Department, Hospital General Universitario Gregorio Marañón, Madrid, Facultad de Medicina, Universidad Complutense de Madrid (UCM), Spain
| | - Manuel Méndez-Bailón
- Internal Medicine Department, Hospital Universitario Clínico San Carlos, Facultad de Medicina, Universidad Complutense de Madrid (UCM), Madrid, Spain
| | - Nuria Muñoz-Rivas
- Medicine Department, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Rodrigo Jiménez-García
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Rey Juan Carlos University, Alcorcón, Madrid, Spain
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Tan AYM, Krishnan JA. How Long Should We Be Vigilant after a Hospitalization for a Chronic Obstructive Pulmonary Disease Exacerbation? Am J Respir Crit Care Med 2019; 197:975-977. [PMID: 29361237 DOI: 10.1164/rccm.201712-2612ed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Ai-Yui M Tan
- 1 Division of Pulmonary, Critical Care, Sleep, and Allergy University of Illinois at Chicago Chicago, Illinois and
| | - Jerry A Krishnan
- 1 Division of Pulmonary, Critical Care, Sleep, and Allergy University of Illinois at Chicago Chicago, Illinois and.,2 Population Health Sciences Program University of Illinois Hospital & Health Sciences System Chicago, Illinois
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Goto T, Hirayama A, Faridi MK, Camargo CA Jr, Hasegawa K. Obesity and Severity of Acute Exacerbation of Chronic Obstructive Pulmonary Disease. Ann Am Thorac Soc 2018; 15:184-91. [PMID: 29053337 DOI: 10.1513/AnnalsATS.201706-485OC] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
RATIONALE Obesity is relatively common among individuals with chronic obstructive pulmonary disease (COPD). However, little is known about the association of obesity with severity of acute exacerbation of COPD and in-hospital mortality. OBJECTIVES To examine the association of obesity with markers of severity of acute exacerbation of COPD and in-hospital mortality. METHODS This is a population-based, retrospective cohort study using the 2012-2013 State Inpatient Databases of seven U.S. states (Arkansas, Florida, Iowa, Nebraska, New York, Utah, and Washington). We included adults (aged ≥40 yr) hospitalized for acute exacerbation of COPD. Obesity, use of noninvasive positive pressure ventilation (NIPPV), and use of invasive mechanical ventilation were determined by International Classification of Diseases, Ninth Revision codes. To examine associations between obesity and each outcome (NIPPV, invasive mechanical ventilation, hospital length of stay (LOS), and in-hospital mortality), we fit unadjusted and adjusted logistic regression models using generalized estimating equations to account for patient clustering within hospitals. We adjusted for age, sex, race/ethnicity, primary payer, median household income, patient residence, hospitalization year, chronic comorbidities, and hospital state. In the sensitivity analysis, we used stabilized inverse probability weighting to estimate the causal relation of obesity with outcomes in this observational study. RESULTS Of 187,647 patients hospitalized for an acute exacerbation of COPD, 17% were obese. Obesity was associated with increased use of both NIPPV (12.0% vs. 6.5%; adjusted odds ratio [OR] = 1.86; 95% confidence interval [CI] = 1.77-1.95; P < 0.001) and invasive mechanical ventilation (3.5% vs. 2.8%; adjusted OR = 1.13; 95% CI = 1.04-1.22; P = 0.003). Similarly, obese patients were more likely to have a hospital LOS of 4 days or longer (57.9% vs. 50.3%; adjusted OR = 1.37; 95% CI = 1.33-1.41; P < 0.001). In contrast, obesity was associated with a lower in-hospital mortality (0.9% vs. 1.4%; unadjusted OR = 0.63; 95% CI = 0.56-0.72; P < 0.001). After adjusting for potential confounders, this association was no longer statistically significant (adjusted OR = 0.86; 95% CI = 0.75-1.00; P = 0.06). Results were similar in sensitivity analyses using stabilized inverse probability weighting. CONCLUSIONS In this population-based study of adults hospitalized with an acute exacerbation of COPD, obesity was associated with increased use of noninvasive and invasive ventilation, increased hospital LOS, but was not associated with increased in-hospital mortality.
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Wittbrodt ET, Millette LA, Evans KA, Bonafede M, Tkacz J, Ferguson GT. Differences in health care outcomes between postdischarge COPD patients treated with inhaled corticosteroid/long-acting β 2-agonist via dry-powder inhalers and pressurized metered-dose inhalers. Int J Chron Obstruct Pulmon Dis 2019; 14:101-114. [PMID: 30613140 PMCID: PMC6307496 DOI: 10.2147/copd.s177213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Purpose The aim of this study was to examine real-world differences in health care resource use (HRU) and costs among COPD patients in the USA treated with a dry powder inhaler (DPI) or pressurized metered-dose inhaler (pMDI) following a COPD-related hospitalization. Methods This retrospective analysis used the Truven MarketScan® databases. Eligibility criteria included 1) age ≥40 years, 2) COPD diagnosis, 3) inpatient admission with a diagnosis of COPD exacerbation, 4) inhaled corticosteroid (ICS)/long-acting β2-agonist (LABA) prescription within 10 days of hospital discharge (index date), and 5) continuous enrollment for 12 months preindex and 90 days postindex. Outcomes included pre- and postindex HRU and costs. DPI and pMDI groups were compared on postindex outcomes via multivariate models controlling for demographic and baseline characteristics. Results The sample included 1,960 DPI and 1,086 pMDI ICS/LABA patients. During the preindex period, pMDI patients were significantly more likely to be prescribed a short-acting β-agonist, experienced more COPD exacerbation-related hospital days, and had a greater number of pulmonologist visits compared to DPI patients (P<0.05), all suggestive of greater disease severity. However, multivariate models revealed that pMDI patients incurred 10% lower all-cause postindex costs (predicted mean costs [2016 US dollars]: $2,673 vs $2,956) and 19% lower COPD-related costs (predicted mean costs: $138 vs $169; P<0.05). Additionally, pMDI patients were 28% less likely to experience a COPD exacerbation-related hospital readmission within 60 days postdischarge compared to the DPI patients (OR: 0.72, 95% CI: 0.52–0.99, P<0.05). Conclusion Despite greater COPD-related HRU and costs preceding index hospitalization, US patients using a pMDI after hospital discharge incurred significantly lower all-cause and COPD-related health care costs compared with those using a DPI, in addition to a decreased likelihood of a COPD exacerbation-related hospital readmission. Results suggest that inhaler device type may influence COPD outcomes and that COPD patients may derive greater clinical benefit from treatment delivered via pMDI vs DPI.
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Affiliation(s)
| | | | - Kristin A Evans
- Life Sciences, Value-Based Care, IBM Watson Health, Cambridge, MA, USA
| | - Machaon Bonafede
- Life Sciences, Value-Based Care, IBM Watson Health, Cambridge, MA, USA
| | - Joseph Tkacz
- Life Sciences, Value-Based Care, IBM Watson Health, Cambridge, MA, USA
| | - Gary T Ferguson
- Pulmonary Research Institute of Southeast Michigan, Farmington Hills, MI, USA
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Goto T, Shimada YJ, Faridi MK, Camargo CA, Hasegawa K. Incidence of Acute Cardiovascular Event After Acute Exacerbation of COPD. J Gen Intern Med 2018; 33:1461-1468. [PMID: 29948806 PMCID: PMC6108996 DOI: 10.1007/s11606-018-4518-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 04/12/2018] [Accepted: 05/24/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND There is a lack of comprehensive view of the association between acute exacerbation of COPD (AECOPD) and the risk of acute cardiovascular events. OBJECTIVE To determine the association of AECOPD with 30-day and 1-year incidences of acute cardiovascular event. DESIGN Self-controlled case series analysis using population-based datasets from three US states from 2005 through 2011. PARTICIPANTS Patients aged ≥ 40 years with AECOPD. MAIN MEASURES The primary outcome was a composite of an ED visit or hospitalization for acute cardiovascular events, including acute myocardial infarction, heart failure, atrial fibrillation, pulmonary embolism, and stroke. We compared the incidence of each patient's acute cardiovascular event during the first 30-day period before the index AECOPD (30-day reference period) in comparison with that during the 30-day period after the index AECOPD. Likewise, with the 1-year period before the index AECOPD as reference, we also estimated incidence rate ratios (IRRs) for each patient's outcomes during 1-year period after the index AECOPD. KEY RESULTS Overall, there were 362,867 patients with an ED visit or hospitalization for AECOPD. Compared with the 30-day reference period, the incidence of acute cardiovascular event in the 30-day period after the AECOPD was significantly higher (IRR, 1.34; 95%CI, 1.30-1.39; P < 0.001). Likewise, compared with the 1-year reference period, the incidence during the 1-year period after the AECOPD was also higher (IRR, 1.20; 95%CI, 1.18-1.22; P < 0.001). For each of acute cardiovascular conditions, the associations remained significant (all P < 0.05). CONCLUSIONS AECOPD was associated with increased 30-day and 1-year incidences of acute cardiovascular event.
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Affiliation(s)
- Tadahiro Goto
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA.
| | - Yuichi J Shimada
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Kohei Hasegawa
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
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Jacobs DM, Noyes K, Zhao J, Gibson W, Murphy TF, Sethi S, Ochs-Balcom HM. Early Hospital Readmissions after an Acute Exacerbation of Chronic Obstructive Pulmonary Disease in the Nationwide Readmissions Database. Ann Am Thorac Soc 2018; 15:837-845. [PMID: 29611719 PMCID: PMC6207114 DOI: 10.1513/annalsats.201712-913oc] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Accepted: 03/27/2018] [Indexed: 01/22/2023] Open
Abstract
RATIONALE Understanding the causes and factors related to readmission for an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) within a nationwide database including all payers and ages can provide valuable input for the development of generalizable readmission reduction strategies. OBJECTIVES To determine the rates, causes, and predictors for early (3-, 7-, and 30-d) readmission in patients hospitalized with AECOPD in the United States using the Nationwide Readmission Database after the initiation of the Hospital Readmissions Reduction Program, but before its expansion to COPD. METHODS We conducted an analysis of the Nationwide Readmission Database from 2013 to 2014. Index admissions and readmissions for an AECOPD were defined consistent with Hospital Readmissions Reduction Program guidelines. We investigated the percentage of 30-day readmissions occurring each day after discharge and the most common readmission diagnoses at different time periods after hospitalization. The relationship between predictors (categorized as patient, clinical, and hospital factors) and early readmission were evaluated using a hierarchical two-level logistic model. To examine covariate effects on early-day readmission, predictors for 3-, 7-, and 30-day readmissions were modeled separately. RESULTS There were 202,300 30-day readmissions after 1,055,830 index AECOPD admissions, a rate of 19.2%. The highest readmission rates (4.2-5.5%) were within the first 72 hours of discharge, and 58% of readmissions were within the first 15 days. Respiratory-based diseases were the most common reasons for readmission (52.4%), and COPD was the most common diagnosis (28.4%). Readmission diagnoses were similar at different time periods after discharge. Early readmission was associated with patient (Medicaid payer status, lower household income, and higher comorbidity burden) and clinical factors (longer length of stay and discharge to a skilled nursing facility). Predictors did not vary substantially by time of readmission after discharge within the 30-day window. CONCLUSIONS Thirty-day readmissions after an AECOPD remain a major healthcare burden, and are characterized by a similar spectrum of readmission diagnoses. Predictors associated with readmission include both patient and clinical factors. Development of a COPD-specific risk stratification algorithm based on these factors may be necessary to better predict patients with AECOPD at high risk of early readmission.
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Affiliation(s)
- David M. Jacobs
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences
| | - Katia Noyes
- Department of Epidemiology and Environmental Health, School of Public Health and Health Professions
| | - Jiwei Zhao
- Department of Biostatistics, School of Public Health and Health Professions, and
| | - Walter Gibson
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences
| | - Timothy F. Murphy
- Department of Medicine, Clinical and Translational Research Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York
| | - Sanjay Sethi
- Department of Medicine, Clinical and Translational Research Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York
| | - Heather M. Ochs-Balcom
- Department of Epidemiology and Environmental Health, School of Public Health and Health Professions
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