Incidence and Mortality of Children Receiving Home Mechanical Ventilation

OBJECTIVES

The incidence, as well as the predictors of mortality, for children receiving home mechanical ventilation (HMV) using population-based data in Canada is a current knowledge gap. Our objectives were to describe HMV incidence and mortality rates, and associations of demographic and clinical variables on mortality.

METHODS

Using Ontario health and demographic administrative databases, we conducted a retrospective cohort study (April 1, 2003-March 31, 2017) of children aged 0 to 17 years receiving HMV via invasive mechanical ventilation and noninvasive ventilation. We identified children with complex chronic conditions. We used data from Census Canada to calculate incidence rates and Cox proportional hazards modeling to assess for predictors of mortality.

RESULTS

We identified 906 children with a mean (SD) crude incidence rate of 2.4 (0.6) per 100 000 for pediatric HMV approvals that increased by 37% over the 14-year study period. Compared with children who were invasively ventilated, we found mortality was associated with noninvasive ventilation (adjusted hazard ratio [aHR], 1.9; 95% confidence interval [CI], 1.3-2.8). Mortality was highest in children from families in the lowest income quintile (aHR, 2.5; 95% CI, 1.5-4.0), those with neurologic impairment complex chronic conditions (aHR, 2.9; 95% CI, 1.4-6.4), those aged 11 to 17 years at HMV initiation (aHR, 1.5; 95% CI, 1.1-2.0), and those with higher health care costs in the 1 year before HMV initiation (aHR, 1.5; 95% CI, 1.3-1.7).

CONCLUSIONS

The incidence of children receiving HMV increased substantially over the 14-year period. Demographic variables associated with increased mortality were identified, suggesting areas requiring greater attention for care providers.

Survival and health care costs after inpatient elective surgery: comparison of patients with and without chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is common among surgical patients, and patients with COPD have higher risk for complications and death within 30 days after surgery. We sought to describe the longer-term postoperative survival and costs of patients with COPD compared with those without COPD within 1 year after inpatient elective surgery.

METHODS

In this retrospective population-based cohort study, we used linked health administrative databases to identify all patients undergoing inpatient elective surgery in Ontario, Canada, from 2005 to 2019. We ascertained COPD status using validated definitions. We followed participants for 1 year after surgery to evaluate survival and costs to the health system. We quantified the association of COPD with survival (Cox proportional hazards models) and costs (linear regression model with log-transformed costs) with partial adjustment (for sociodemographic factors and procedure type) and full adjustment (also adjusting for comorbidities). We assessed for effect modification by frailty, cancer and procedure type.

RESULTS

We included 932 616 patients, of whom 170 482 (18%) had COPD. With respect to association with risk of death, COPD had a partially adjusted hazard ratio (HR) of 1.61 (95% confidence interval [CI] 1.58-1.64), and a fully adjusted HR of 1.26 (95% CI 1.24-1.29). With respect to impact on health system costs, COPD was associated with a partially adjusted relative increase of 13.1% (95% CI 12.7%-13.4%), and an increase of 4.6% (95% CI 4.3%-5.0%) with full adjustment. Frailty, cancer and procedure type (such as orthopedic and lower abdominal surgery) modified the association between COPD and outcomes.

INTERPRETATION

Patients with COPD have decreased survival and increased costs in the year after surgery. Frailty, cancer and the type of surgical procedure modified associations between COPD and outcomes, and must be considered when risk-stratifying surgical patients with COPD.

Prevalence and characteristics of progressive fibrosing interstitial lung disease in a prospective registry

BACKGROUND

Progressive fibrosing interstitial lung disease (PF-ILD) is characterised by progressive physiological, symptomatic and/or radiographic worsening. The real-world prevalence and characteristics of PF-ILD remain uncertain.

METHODS

Patients were enrolled from the Canadian Registry for Pulmonary Fibrosis between 2015 and 2020. PF-ILD was defined as a relative forced vital capacity (FVC) decline ≥10%, death, lung transplantation or any two of: relative FVC decline ≥5% and <10%, worsening respiratory symptoms or worsening fibrosis on computed tomography of the chest, all within 24 months of diagnosis. Time-to-event analysis compared progression between key diagnostic subgroups. Characteristics associated with progression were determined by multivariable regression.

RESULTS

Of 2746 patients with fibrotic ILD (mean±sd age 65±12 years; 51% female), 1376 (50%) met PF-ILD criteria in the first 24 months of follow-up. PF-ILD occurred in 427 (59%) patients with idiopathic pulmonary fibrosis (IPF), 125 (58%) with fibrotic hypersensitivity pneumonitis (HP), 281 (51%) with unclassifiable ILD (U-ILD) and 402 (45%) with connective tissue disease-associated ILD (CTD-ILD). Compared with IPF, time to progression was similar in patients with HP (hazard ratio (HR) 0.96, 95% CI 0.79-1.17), but was delayed in patients with U-ILD (HR 0.82, 95% CI 0.71-0.96) and CTD-ILD (HR 0.65, 95% CI 0.56-0.74). Background treatment varied across diagnostic subtypes, with 66% of IPF patients receiving antifibrotic therapy, while immunomodulatory therapy was utilised in 49%, 61% and 37% of patients with CHP, CTD-ILD and U-ILD, respectively. Increasing age, male sex, gastro-oesophageal reflux disease and lower baseline pulmonary function were independently associated with progression.

CONCLUSIONS

Progression is common in patients with fibrotic ILD, and is similarly prevalent in HP and IPF. Routinely collected variables help identify patients at risk for progression and may guide therapeutic strategies.

Trends in all-cause mortality and inpatient and outpatient visits for ambulatory care sensitive conditions during the first year of the COVID-19 pandemic: A population-based study

BACKGROUND

The impact of the COVID-19 pandemic on the management of ambulatory care sensitive conditions (ACSCs) remains unknown.

OBJECTIVES

To compare observed and expected (projected based on previous years) trends in all-cause mortality and healthcare use for ACSCs in the first year of the pandemic (March 2020 to March 2021).

DESIGN, SETTING AND PARTICIPANTS

We conducted a population-based study using provincial health administrative data on general adul population (Ontario, Canada).

OUTCOMES AND MEASURES

Monthly all-cause mortality, and hospitalizations, emergency department (ED) and outpatient visit rates (per 100,000 people at-risk) for seven combined ACSCs (asthma, chronic obstructive pulmonary disease, angina, congestive heart failure, hypertension, diabetes, and epilepsy) during the first year were compared with similar periods in previous years (2016-2019) by fitting monthly time series autoregressive integrated moving-average models.

RESULTS

Compared to previous years, all-cause mortality rates increased at the beginning of the pandemic (observed rate in March to May 2020 of 79.98 vs. projected of 71.24 [66.35-76.50]) and then returned to expected in June 2020-except among immigrants and people with mental health conditions where they remained elevated. Hospitalization and ED visit rates for ACSCs remained lower than projected throughout the first year: observed hospitalization rate of 37.29 versus projected of 52.07 (47.84-56.68); observed ED visit rate of 92.55 versus projected of 134.72 (124.89-145.33). ACSC outpatient visit rates decreased initially (observed rate of 4299.57 vs. projected of 5060.23 [4712.64-5433.46]) and then returned to expected in June 2020.

Prescription Pathways from Initial Medication Use to Triple Therapy in Older COPD Patients: A Real-World Population Study

BACKGROUND AND OBJECTIVE

Triple therapy with an inhaled corticosteroid (ICS), a long-acting β₂-agonist bronchodilator (LABA) and a long-acting muscarinic antagonist (LAMA) is recommended as step-up therapy for chronic obstructive pulmonary disease (COPD) patients who continue to have persistent symptoms and increased risk of exacerbation despite treatment with dual therapy. We sought to evaluate different treatment pathways through which COPD patients were escalated to triple therapy.

METHODS

We used population health databases from Ontario, Canada to identify individuals aged 66 or older with COPD who started triple therapy between 2014 and 2017. Median time from diagnosis to triple therapy was estimated using the Kaplan-Meier method. We classified treatment pathways based on treatments received prior to triple therapy and evaluated whether pathways differed by exacerbation history, blood eosinophil counts or time period.

RESULTS

Among 4108 COPD patients initiating triple therapy, only 41.2% had a COPD exacerbation in the year prior. The three most common pathways were triple therapy as initial treatment (32.5%), LAMA to triple therapy (29.8%), and ICS + LABA to triple therapy (15.4%). Median time from diagnosis to triple therapy was 362 days (95% confidence interval:331-393 days) overall, but 14 days (95% CI 12-17 days) in the triple therapy as initial treatment pathway. This pathway was least likely to contain patients with frequent or severe exacerbations (22.0% vs. 31.5%, p < 0.001) or with blood eosinophil counts ≥300 cells/µL (18.9% vs. 22.0%, p < 0.001).

CONCLUSION

Real-world prescription of triple therapy often does not follow COPD guidelines in terms of disease severity and prior treatments attempted.

Inhalational exposures in patients with fibrotic interstitial lung disease: Presentation, pulmonary function and survival in the Canadian Registry for Pulmonary Fibrosis

BACKGROUND AND OBJECTIVE

Inhalational exposures are a known cause of interstitial lung disease (ILD), but little is understood about their prevalence across ILD subtypes and their relationship with pulmonary function and survival.

METHODS

Patients with fibrotic ILD were identified from the multicentre Canadian Registry for Pulmonary Fibrosis. Patients completed questionnaires regarding ILD-related occupational and environmental exposures. The relationship between exposures and the outcomes of baseline age, gender, family history, pulmonary function and survival was analysed using linear and logistic regression models, linear mixed-effect regression models and survival analysis using multivariable Cox proportional hazards along with the log-rank test.

RESULTS

There were 3820 patients included in this study, with 2385 (62%) having ILD-related inhalational exposure. Exposed patients were younger, particularly in the idiopathic pulmonary fibrosis subgroup. Inhalational exposure was associated with male gender (adjusted OR 1.46, 95% CI 1.28-1.68, p < 0.001) and family history of pulmonary fibrosis (adjusted OR 1.73, 95% CI 1.40-2.15, p < 0.001). Patients with any inhalational exposure had improved transplant-free survival (hazard ratio 0.81, 95% CI 0.71-0.92, p = 0.001); this effect persisted across diagnostic subtypes. The relationship between exposures and annual change in forced vital capacity varied by ILD subtype.

CONCLUSION

Patients with fibrotic ILD report high prevalence of inhalational exposures across ILD subtypes. These exposures were associated with younger age at diagnosis, male gender and family history of pulmonary fibrosis. Identification of an inhalational exposure was associated with a survival benefit. These findings suggest that inhaled exposures may impact clinical outcomes in patients with ILD, and future work should characterize the mechanisms underlying these relationships.

Association of BMI and Change in Weight With Mortality in Patients With Fibrotic Interstitial Lung Disease

BACKGROUND

Mortality risk assessment in interstitial lung disease (ILD) is challenging. Our objective was to determine the prognostic significance of BMI and change in weight in the most common fibrotic ILD subtypes.

RESEARCH QUESTION

Could BMI and weight loss over time be reliable prognostic indicators in patients with fibrotic ILD?

STUDY DESIGN AND METHODS

This observational retrospective multicenter cohort study enrolled patients with fibrotic ILD from the six-center CAnadian REgistry for Pulmonary Fibrosis (CARE-PF, derivation) and the ILD registry at the University of California, San Francisco (UCSF, validation). Patients were subcategorized as underweight (BMI < 18.5), normal weight (BMI 18.5-24.9), overweight (BMI 25-29.9), or obese (BMI > 30). Annual change in weight was calculated for all years of follow-up as the slope of best fit using the least square method based on every available measurement. Separate multivariable analyses evaluated the associations of BMI and change in weight with mortality, adjusting for common prognostic variables.

RESULTS

The derivation and validation cohorts included 1,786 and 1,779 patients, respectively. Compared with patients with normal BMI, mortality was highest in patients who were underweight (hazard ratio [HR], 3.19; 95% CI, 1.88-5.43; P < .001) and was lowest in those who were overweight (HR, 0.52; 95% CI, 0.36-0.75; P < .001) or obese (HR, 0.55; 95%CI, 0.37-0.83; P < .001) in the analysis adjusted for the ILD-GAP (gender, age, physiology) Index. Patients who had a weight loss of at least 2 kg within 1 year had increased risk of death in the subsequent year (HR, 1.41; 95% CI, 1.01-1.97; P = .04) after adjustment for the ILD-GAP Index and baseline BMI category, with a plateau in risk for patients with greater weight loss. Consistent results were observed in the validation cohort.

INTERPRETATION

Both BMI and weight loss are independently associated with 1-year mortality in fibrotic ILD. BMI and weight loss may be clinically useful prognostic indicators in fibrotic ILD.

Is Overreliance on SABA Associated with Health Risks in the Older Asthma Population?

Recent Global Initiative for Asthma (GINA) recommendations reduce the role of short-acting β₂-agonist (SABA) premised on the associated exacerbation risk. The widely accepted SABA risk profile is based on limited data described 30 years ago. This GINA paradigm shift demands an examination of SABA risks in a modern therapeutic era. Recent studies confirm that SABA overuse is common and associated with adverse outcomes. This study aimed to determine associations between SABA use, all-cause mortality and asthma exacerbations in an older North American asthma population.

In this population-based cohort study, individuals with prevalent asthma (2006–2015) aged ≥65 years, eligible for provincial drug coverage, were included. Annual SABA canisters filled (0, 1–2, 3–5, ≥6) was the primary exposure. Hazard ratios (HRs) with 95% CIs were estimated using Cox proportional hazard regression, adjusted for confounders.

There were 59 533 asthma individuals; 14% overused SABA (≥3 canisters annually). Compared to those who used <3 canisters, the adjusted HRs of death for those who used 3–5 and ≥6 canisters were 1.11 (95% CI: 1.02–1.22, p=0.0157) and 1.56 (95% CI: 1.41–1.71, p<0.0001), respectively. Severe asthma exacerbation rates for ≥3 and <3 canisters/year were 7.5% and 2.1%, respectively. The adjusted HRs of severe asthma exacerbations were 1.59 (95% CI: 1.40–1.82, p<0.0001) and 2.26 (95% CI: 1.96–2.60, p<0.0001) in those who used 3–5 and ≥6 SABA canisters per year, respectively.

In Canada, 1 in 7 individuals with asthma overused SABA associated with increased risks of severe asthma exacerbations and death. The adverse impacts of SABA overuse continue 30 years after early publications.

These results in older people with asthma add strength to previously documented associations of SABA use, severe asthma exacerbations and death. Clinicians may consider these safety results when prescribing and assessing new therapeutic recommendations.https://bit.ly/34Gr56P

Ophthalmologic assessments in patients with newly diagnosed sarcoidosis: An observational study from a universal healthcare system

INTRODUCTION

Consensus guidelines for the management of sarcoidosis recommend screening eye examinations for all patients, even in those without ocular symptoms. We aimed to determine the proportion of sarcoidosis patients that complete ophthalmologic evaluations and factors associated with their performance.

METHODS

We identified patients with sarcoidosis using population health services data from Ontario, Canada between 1991 and 2019. Sarcoidosis was defined by ≥ 2 physician visits for sarcoidosis within a two-year period. Ophthalmologic evaluations were based on an optometrist or ophthalmologist visit within the year prior or two years following the diagnosis. We estimated correlations between the number of eye care professionals and proportion of sarcoidosis patients completing ophthalmologic assessments within regional health units. We evaluated for associations between ophthalmologic screening and patient characteristics using multivariable logistic regression.

RESULTS

We identified 21,679 patients with sarcoidosis in Ontario. An ophthalmologic evaluation was performed in 14,751 (68.0%), with a similar number of individuals seeing ophthalmologists and optometrists (43.7% vs. 42.2%). The percentage of sarcoidosis patients undergoing an ophthalmologic evaluation within corresponding regional health units was moderately correlated with the number of practicing ophthalmologists (r = 0.64, p = 0.01), but not the number of optometrists (r = 0.08, p = 0.77). Patients who were older [OR per year 1.02 (95% CI 1.01-1.02), p < 0.001] and female [OR 1.54 (95% CI 1.44-1.63), p < 0.001] were more likely to complete ophthalmologic evaluations. Immigrants to Canada were less likely to undergo ophthalmologic assessments [OR 0.66 (95% CI 0.60-0.73), p < 0.001].

CONCLUSIONS

Most patients with sarcoidosis complete ophthalmologic examinations, though a substantial proportion does not. Young adults, men and immigrants were less likely to complete ophthalmologic evaluations. Limited access to ophthalmologists may at least in part explain why some sarcoidosis patients fail to complete ophthalmologic screening.

Validation and minimum important difference of the UCSD Shortness of Breath Questionnaire in fibrotic interstitial lung disease

RATIONALE

The University of California, San Diego Shortness of Breath Questionnaire (UCSDSOBQ) is a frequently used domain-specific dyspnea questionnaire; however, there is little information available regarding its use and minimum important difference (MID) in fibrotic interstitial lung disease (ILD). We aimed to describe the key performance characteristics of the UCSDSOBQ in this population.

METHODS

UCSDSOBQ scores and selected anchors were measured in 1933 patients from the prospective multi-center Canadian Registry for Pulmonary Fibrosis. Anchors included the St. George's Respiratory Questionnaire (SGRQ), European Quality of Life 5 Dimensions 5 Levels questionnaire (EQ-5D-5L) and EQ visual analogue scale (EQ-VAS), percent-predicted forced vital capacity (FVC%), diffusing capacity of the lung for carbon monoxide (DLCO%), and 6-min walk distance (6MWD). Concurrent validity, internal consistency, ceiling and floor effects, and responsiveness were assessed, followed by estimation of the MID by anchor-based (linear regression) and distribution-based methods (standard error of measurement).

RESULTS

The UCSDSOBQ had a high level of internal consistency (Cronbach's alpha = 0.97), no obvious floor or ceiling effect, strong correlations with SGRQ, EQ-5D-5L, and EQ-VAS (|r| > 0.5), and moderate correlations with FVC%, DLCO%, and 6MWD (0.3 < |r| < 0.5). The MID estimate for UCSDSOBQ was 5 points (1-8) for the anchor-based method, and 4.5 points for the distribution-based method.

CONCLUSION

This study demonstrates the validity of UCSDSOBQ in a large and heterogeneous population of patients with fibrotic ILD, and provides a robust MID estimate of 5-8 points.

Specialist Care in Individuals With Asthma Who Required Hospitalization: A Retrospective Population-Based Study

BACKGROUND

Patients who are at risk for severe asthma exacerbations should receive specialist care. However, the care pattern for such patients in the real world is unclear.

OBJECTIVE

To describe the pattern of care among individuals with asthma who required hospitalization, and to identify factors associated with receiving asthma specialist care.

METHODS

This was a retrospective population-based study using health administrative data from two Canadian provinces. Individuals aged 14 to 45 years who were newly diagnosed with asthma between 2006 and 2016 and had at least one hospitalization for asthma at or within 5 years after the initial asthma diagnosis were included. First, we calculated frequencies of primary and specialist care around the asthma diagnosis: 1 year before and 2 years after in a 6-month period. Next, among individuals diagnosed with asthma by a primary care physician, we used multivariable Cox regressions to identify factors associated with receiving specialist care.

RESULTS

For 1862 individuals included, we found that most (≥71% per time period) were cared for by primary care physicians 1 year before and 2 years after the asthma diagnosis; the percentage of individuals seen at least once by a specialist for asthma and/or asthma-related respiratory conditions during the first 6 months since the diagnosis did not exceed 40%. Among 1411 of 1862 individuals who were under primary care before the asthma diagnosis (76%), controlling for covariates, living in a rural area or a low-income neighborhood was associated with less likelihood of receiving specialist care.

CONCLUSIONS

Despite recommendations, more than half of individuals with asthma who required hospitalization did not receive specialist care during the first 2 years since the diagnosis. Identified factors associated with receiving asthma specialist care suggested that access is an important barrier to receiving recommended care.

Case-Ascertainment Models to Identify Adults with Obstructive Sleep Apnea Using Health Administrative Data: Internal and External Validation

Background

There is limited evidence on whether obstructive sleep apnea (OSA) can be accurately identified using health administrative data.

Study Design and Methods

We derived and validated a case-ascertainment model to identify OSA using linked provincial health administrative and clinical data from all consecutive adults who underwent a diagnostic sleep study (index date) at two large academic centers (Ontario, Canada) from 2007 to 2017. The presence of moderate/severe OSA (an apnea–hypopnea index≥15) was defined using clinical data. Of 39 candidate health administrative variables considered, 32 were tested. We used classification and regression tree (CART) methods to identify the most parsimonious models via cost-complexity pruning. Identified variables were also used to create parsimonious logistic regression models. All individuals with an estimated probability of 0.5 or greater using the predictive models were classified as having OSA.

Results

The case-ascertainment models were derived and validated internally through bootstrapping on 5099 individuals from one center (33% moderate/severe OSA) and validated externally on 13,486 adults from the other (45% moderate/severe OSA). On the external cohort, parsimonious models demonstrated c-statistics of 0.75–0.81, sensitivities of 59–60%, specificities of 87–88%, positive predictive values of 79%, negative predictive values of 73%, positive likelihood ratios (+LRs) of 4.5–5.0 and –LRs of 0.5. Logistic models performed better than CART models (mean integrated calibration indices of 0.02–0.03 and 0.06–0.12, respectively). The best model included: sex, age, and hypertension at the index date, as well as an outpatient specialty physician visit for OSA, a repeated sleep study, and a positive airway pressure treatment claim within 1 year since the index date.

Interpretation

Among adults who underwent a sleep study, case-ascertainment models for identifying moderate/severe OSA using health administrative data had relatively low sensitivity but high specificity and good discriminative ability. These findings could help study trends and outcomes of OSA individuals using routinely collected health care data.

FACTORS ASSOCIATED WITH NON-RECEIPT OF RECOMMENDED CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) MEDICATIONS: A POPULATION STUDY

BACKGROUND

Chronic obstructive pulmonary disease (COPD) medications reduce exacerbations and improve quality of life. Despite this, some individuals do not receive medications recommended by practise guidelines.

RESEARCH QUESTION

How common is non-receipt of recommended medications among people with COPD and what are factors associated with non-receipt?

STUDY DESIGN AND METHODS

We conducted a population cohort study in Ontario, Canada, a province with universal health care insurance and medication coverage for those aged 65 and older. Health administrative data were used to identify people 66 years of age or older with physician-diagnosed COPD as of 2018 and group them into lower or higher risk for future COPD exacerbation groups. Proportions of patients in each group who did not receive medications recommended by COPD guidelines were determined. Generalized estimating equation modelling was used to determine associations between patient and physician factors and non-receipt of recommended medications.

RESULTS

About 54% and 88% of people with COPD receoved sufficient recommended medications in the low and high risk of exacerbation groups, respectively. Longer duration of COPD, higher comorbidity, dementia, and older physician age were associated with non-receipt of recommended medications in both groups. People who had a co-diagnosis of asthma and who received care by a pulmonologist and spirometry were more likely to receive recommended medication .

INTERPRETATION

COPD medications appear underused by the COPD population and various factors are associated with sub-optimal receipt. Targeting these factors would help improve the care and health of people with COPD.

Morbidity and mortality reduction associated with polysomnography testing in idiopathic pulmonary fibrosis: a population-based cohort study

Background

It is not well-known if diagnosing and treating sleep breathing disorders among individuals with idiopathic pulmonary fibrosis (IPF) improves health outcomes. We evaluated the association between receipt of laboratory-based polysomnography (which is the first step in the diagnosis and treatment of sleep breathing disorders in Ontario, Canada) and respiratory-related hospitalization and all-cause mortality among individuals with IPF.

Methods

We used a retrospective, population-based, cohort study design, analyzing health administrative data from Ontario, Canada, from 2007 to 2019. Individuals with IPF were identified using an algorithm based on health administrative codes previously developed by IPF experts. Propensity score matching was used to account for potential differences in 41 relevant covariates between individuals that underwent polysomnography (exposed) and individuals that did not undergo polysomnography (controls), in order minimize potential confounding. Respiratory-related hospitalization and all-cause mortality were evaluated up to 12 months after the index date.

Results

Out of 5044 individuals with IPF identified, 201 (4.0%) received polysomnography, and 189 (94.0%) were matched to an equal number of controls. Compared to controls, exposed individuals had significantly reduced rates of respiratory-related hospitalization (hazard ratio [HR] 0.43, 95% confidence interval [CI] 0.24–0.75), p = 0.003) and all-cause mortality (HR 0.49, 95% CI 0.30–0.80), p = 0.004). Significantly reduced rate of respiratory-related hospitalization (but not all-cause mortality) was also observed among those with >  = 1 respiratory-related hospitalization (HR 0.38, 95% CI 0.15–0.99) and systemic corticosteroid receipt (HR 0.37, 95% CI 0.19–0.94) in the year prior to the index date, which reflect sicker subgroups of persons.

Conclusions

Undergoing polysomnography was associated with significantly improved clinically-important health outcomes among individuals with IPF, highlighting the potential importance of incorporating this testing in IPF disease management.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-021-01555-x.

Long-term macrolide therapy for chronic obstructive pulmonary disease: a population-based time series analysis

BACKGROUND

Macrolides are recommended as an adjunctive treatment for patients with moderate to severe chronic obstructive pulmonary disease (COPD) who experience recurrent exacerbations. The objective of this study was to examine temporal trends in the provision of long-term macrolide therapy, specifically before and after publication of the landmark MACRO trial in August 2011 showing efficacy of macrolides for this indication.

METHODS

We performed an interrupted time series analysis using population-level health administrative data. The study cohort consisted of all Ontario residents who had COPD, were using at least 1 long-acting inhaler, and were aged 65 years and older between Apr. 1, 2004, and Mar. 31, 2018. We compared the baseline characteristics of eligible patients before and after publication of the MACRO trial. Our primary outcome was overall prevalence of long-term macrolide therapy; secondary outcomes were incidence of COPD-related hospitalizations, emergency department visits and outpatient exacerbations requiring high-dose steroids in each quarter. We performed an interrupted time series analysis to assess for changes in the incidence of macrolide prophylaxis by quarter-year over the study period.

RESULTS

The rate of long-term macrolide use increased from 0.8 per 1000 people in 2004 to 13.8 per 1000 people in 2018 (in the severe COPD group, the rate increased from 1.3 to 32.3 per 1000 people). The interrupted time series analysis showed that, before 2011, the prevalence of macrolide prophylaxis increased at a rate of 0.44 (95% confidence interval [CI] 0.39-0.50) per 1000 people per year; after 2011, the rate of increase grew by 1.18 (95% CI 1.07-1.29) per 1000 people to 1.63 (95% CI 1.56-1.69) per 1000 people per year. The seasonal pattern of COPD-related health care visits remained stable over the study period, and there was no detectable reduction in hospitalizations or emergency department visits at the population level.

INTERPRETATION

In the past decade, there has been a significant rise in the use of long-term macrolide therapy for patients with COPD. As this practice becomes increasingly common, it will be important to monitor its potential benefits on COPD exacerbations but also its potential effects on adverse events and antimicrobial resistance patterns.