The economic burden of COPD

Large-scale, ion-current-based proteomics investigation of bronchoalveolar lavage fluid in chronic obstructive pulmonary disease patients

Proteomic analysis of bronchoalveolar lavage fluid (BALF) in chronic obstructive pulmonary disease (COPD) patients may provide new biomarkers and deeper understanding of the disease mechanisms but remains challenging. Here we describe an ion-current-based strategy for comparative analysis of BALF proteomes from patients with moderate and stable COPD versus healthy controls. The strategy includes an efficient preparation procedure providing quantitative recovery and a nano-LC/MS analysis with a long, heated column. Under optimized conditions, high efficiency and reproducibility were achieved for each step, enabling a "20-plex" comparison of clinical subjects (n = 10/group). Without depletion/fractionation, a total of 423 unique protein groups were quantified under stringent criteria with at least two quantifiable peptides. Seventy-six proteins were determined as significantly altered in COPD, which represent a diversity of biological processes such as alcohol metabolic process, gluconeogenesis/glycolysis, inflammatory response, proteolysis, and oxidation reduction. Interestingly, altered alcohol metabolism responding to oxidant stress is a novel observation in COPD. The prominently elevated key enzymes involved in alcohol metabolism (e.g., ADH1B, ALDH2, and ALDH3A1) may provide a reasonable explanation for a bewildering observation in COPD patients known for decades: the underestimation of the blood alcohol concentrations through breath tests. These discoveries could provide new insights for identifying novel biomarkers and pathological mediators in clinical studies.

Long-term telerehabilitation of COPD patients in their homes: interim results from a pilot study in Northern Norway

We investigated the feasibility of a long-term telerehabilitation service for COPD patients comprising exercise training at home, telemonitoring and education/self-management. The service was offered as a 2-year follow-up programme by a physiotherapist. Equipment included a treadmill, a pulse oximeter and a tablet computer. Participants had weekly videoconference sessions with the physiotherapist. A website was used to access a training programme and to fill in a daily diary and a training diary. Ten patients with moderate or severe COPD participated in a pilot study in Northern Norway. After more than one year, all participants were still participating actively and no drop-outs had occurred. On average, there were 2.0 training sessions/week, 3.3 measurements/week registered via the website and 0.5 videoconference contacts/week. There was a reduction of 27% in the COPD-related hospital costs. Feedback from the participants was very positive. Long-term telerehabilitation of COPD patients at home is feasible and interim results suggest that it reduces healthcare utilization.

Evaluation of health care providers' role transition and satisfaction in hospital-at-home for chronic obstructive pulmonary disease exacerbations: a survey study

Background

Hospital-at-home is an accepted alternative for usual hospital treatment for patients with a Chronic Obstructive Pulmonary Disease (COPD) exacerbation. The introduction of hospital-at-home may lead to changes in health care providers’ roles and responsibilities. To date, the impact on providers’ roles is unknown and in addition, little is known about the satisfaction and acceptance of care providers involved in hospital-at-home.

Methods

Objective of this survey study was to investigate the role differentiation, role transitions and satisfaction of professional care providers (i.e. pulmonologists, residents, hospital respiratory nurses, generic and specialised community nurses and general practitioners) from 3 hospitals and 2 home care organisations, involved in a community-based hospital-at-home scheme. A combined multiple-choice and open-end questionnaire was administered in study participants.

Results

Response rate was 10/17 in pulmonologists, 10/23 in residents, 9/12 in hospital respiratory nurses, 15/60 in generic community nurses, 6/10 in specialised community nurses and 25/47 in general practitioners. For between 66% and 100% of respondents the role in early discharge was clear and between 57% and 78% of respondents was satisfied with their role in early discharge. For nurses the role in early discharge was different compared to their role in usual care. 67% of generic community nurses felt they had sufficient knowledge and skills to monitor patients at home, compared to 100% of specialised community nurses. Specialised community nurses felt they should monitor patients. 60% of generic community nurses responded they should monitor patients at home. 78% of pulmonologists, 12% of general practitioners, 55% of hospital respiratory nurses and 48 of community nurses was satisfied with early discharge in general. For coordination of care 29% of community nurses had an unsatisfied response. For continuity of care this was 12% and 10% for hospital respiratory nurses and community nurses, respectively.

Conclusion

A community-based early assisted discharge for COPD exacerbations is possible and well accepted from the perspective of health care providers’ involved. Satisfaction with the different aspects is good and the transfer of patients in the community while supervised by generic community nurses is possible. Attention should be paid to coordination and continuity of care, especially information transfer between providers.

Chronic obstructive pulmonary disease in China: the potential role of indacaterol

Chronic obstructive pulmonary disease (COPD) is becoming a leading cause of morbidity and mortality in China, with tobacco smoking, biomass fuel use and genetic susceptibility being the major risk factors. COPD poses a high economic burden with the total expenditure per patient costing 40% and nearly one-third of an average family income in urban and rural areas of China, respectively. Despite the use of the Global Initiative for Chronic Obstructive Lung Disease strategy document being recommended for the diagnosis and management of COPD, the majority of patients with COPD go undiagnosed or are not managed appropriately by physicians. Long-acting β2-agonists (LABAs) have long been used for symptomatic management of COPD, with salmeterol and formoterol being the commonly used twice-daily treatments. Indacaterol is the first once-daily LABA, approved at a dose of 150 µg once daily in China. Several phase III studies have shown that indacaterol 150 µg improves lung function, breathlessness, health status, exacerbations, rescue medication use and symptoms, as compared with placebo and other bronchodilators, in patients with COPD, with a rapid onset of action following first dose and a good safety and tolerability profile. In this review we elaborate on the efficacy and safety results from several such studies.

Treating neutrophilic inflammation in COPD by targeting ALX/FPR2 resolution pathways

Neutrophilic inflammation persists in COPD despite best current therapies and it is particularly resistant to inhaled glucocorticosteroids. Persistent neutrophil activation not only contributes to matrix breakdown, but can maintain inflammation through the release of endogenous damage associated molecule patterns (DAMPs). Inhibiting excessive neutrophilic inflammation is challenging as many pathogen recognition receptors can initiate migration and the targeting of downstream signaling molecules may compromise essential host defense mechanisms. Here, we discuss new strategies to combat this inflammation in COPD by focusing on the anti-inflammatory role of ALX/FPR2 receptors. ALX/FPR2 is a promiscuous G-protein coupled receptor (GPCR) responding to lipid and peptide agonists that can either switch on acute inflammation or promote resolution of inflammation. We highlight this receptor as an emerging target in the pathogenesis of COPD because known ALX/FPR2 endogenous agonists are enriched in COPD. Serum Amyloid A (SAA) has recently been discovered to be abundantly expressed in COPD and is a potent ALX/FPR2 agonist that unlike almost all other inflammatory chemoattractants, is induced by glucocorticosteroids. SAA not only initiates lung inflammation via ALX/FPR2 but can allosterically modify this receptor so that it no longer transduces pro-resolving signals from endogenous lipoxins that would otherwise promote tissue healing. We propose that there is an imbalance in endogenous and microbial ALX/FPR2 receptor agonists in the inflamed COPD lung environment that oppose protective anti-inflammatory and pro-resolution pathways. These insights open the possibility of targeting ALX/FPR2 receptors using synthetic agonists to resolve persistent neutrophilic inflammation without compromising essential host defense mechanisms.

COPD in the working age population: the economic impact on both patients and government

OBJECTIVES

To explore the full economic impact, on both patients and government, as a result of COPD in the working age population.

METHODS

The economic impact of COPD due to medical treatment, impaired productivity and early retirement was assessed in a cross sectional cost analysis of the Dutch COPD population aged 45-64 years. The costing year was 2009 and input parameters were derived from both national data sources and the international COPD uncovered survey.

RESULTS

While direct medical costs for COPD patients of working age were relatively low (€ 91 million), the amount of lost productivity (income) due to early retirement (€ 223 million) exceeded over two times their medical costs. In addition, costs for the government were considerable because of lost tax revenues (€ 77 million) and COPD related disability pensions paid (€ 180 million). Apart from lost productivity due to early retirement, costs due to impaired productivity for working COPD patients were € 63 million.

CONCLUSIONS

The costs of COPD for both patients of working age as for the government were considerable, making this population a priority for prevention and intervention programs of healthcare providers, employers and government.

Heart failure and chronic obstructive pulmonary disease: the challenges facing physicians and health services

Pulmonary disease is common in patients with heart failure, through shared risk factors and pathophysiological mechanisms. Adverse pulmonary vascular remodelling and chronic systemic inflammation characterize both diseases. Concurrent chronic obstructive pulmonary disease presents diagnostic and therapeutic challenges, and is associated with increased morbidity and mortality. The cornerstones of therapy are beta-blockers and beta-agonists, whose pharmacological properties are diametrically opposed. Each disease is implicated in exacerbations of the other condition, greatly increasing hospitalizations and associated health care costs. Such multimorbidity is a key challenge for health-care systems oriented towards the treatment of individual diseases. Early identification and treatment of cardiopulmonary disease may alleviate this burden. However, diagnostic and therapeutic strategies require further validation in patients with both conditions.

Use of the Chinchilla model to evaluate the vaccinogenic potential of the Moraxella catarrhalis filamentous hemagglutinin-like proteins MhaB1 and MhaB2

Moraxella catarrhalis causes significant health problems, including 15–20% of otitis media cases in children and ∼10% of respiratory infections in adults with chronic obstructive pulmonary disease. The lack of an efficacious vaccine, the rapid emergence of antibiotic resistance in clinical isolates, and high carriage rates reported in children are cause for concern. In addition, the effectiveness of conjugate vaccines at reducing the incidence of otitis media caused by Streptococcus pneumoniae and nontypeable Haemophilus influenzae suggest that M. catarrhalis infections may become even more prevalent. Hence, M. catarrhalis is an important and emerging cause of infectious disease for which the development of a vaccine is highly desirable. Studying the pathogenesis of M. catarrhalis and the testing of vaccine candidates have both been hindered by the lack of an animal model that mimics human colonization and infection. To address this, we intranasally infected chinchilla with M. catarrhalis to investigate colonization and examine the efficacy of a protein-based vaccine. The data reveal that infected chinchillas produce antibodies against antigens known to be major targets of the immune response in humans, thus establishing immune parallels between chinchillas and humans during M. catarrhalis infection. Our data also demonstrate that a mutant lacking expression of the adherence proteins MhaB1 and MhaB2 is impaired in its ability to colonize the chinchilla nasopharynx, and that immunization with a polypeptide shared by MhaB1 and MhaB2 elicits antibodies interfering with colonization. These findings underscore the importance of adherence proteins in colonization and emphasize the relevance of the chinchilla model to study M. catarrhalis–host interactions.

Influenza vaccination in adults with chronic obstructive pulmonary disease: the impact of a diagnostic breathing test on vaccination rates

INTRODUCTION

Influenza vaccination rates are low in adults with chronic obstructive pulmonary disease (COPD). A diagnostic breathing test in adults with COPD may increase vaccination rates; however, research has not demonstrated this relationship. The purpose of this research was to determine if adults with COPD diagnosed by a breathing test were more likely to have had an influenza vaccination during the past 12 months when compared to those with COPD diagnosed without a breathing test.

METHODS

This was a cross-sectional study using data from the 2011 Behavioral Risk Factor Surveillance System. Logistic regression examined the relationship between influenza vaccination among adults with COPD diagnosed with a breathing test (n = 13,201) compared to those diagnosed without a breathing test (n = 3,108), after controlling for all potential confounders.

RESULTS

Overall, 49% of respondents with COPD received an influenza vaccination within the past 12 months and 78% reported their COPD was diagnosed by a breathing test. The prevalence of influenza vaccination in the past 12 months was greater in those with COPD diagnosed by a breathing test (53%) compared to those diagnosed without a breathing test (36%). In adjusted analysis, adults with COPD who had a breathing test were 31% (confidence interval 1.1, 1.6) more likely to have received an influenza vaccination in the past 12 months compared to those without a breathing test.

DISCUSSION

A diagnostic breathing test for COPD was associated with increased likelihood of having had an influenza vaccination in the past 12 months. This may be an indicator of the relationship between knowledge of lung function and the need for preventative care, a sign of quality healthcare, or good health-seeking behaviors in patients with COPD. This research is the first to use a nationally representative sample to suggest that spirometry diagnosis of COPD may increase rates of influenza vaccination.

Moraxella catarrhalis uses a twin-arginine translocation system to secrete the β-lactamase BRO-2

Background

Moraxella catarrhalis is a human-specific gram-negative bacterium readily isolated from the respiratory tract of healthy individuals. The organism also causes significant health problems, including 15-20% of otitis media cases in children and ~10% of respiratory infections in adults with chronic obstructive pulmonary disease. The lack of an efficacious vaccine, the rapid emergence of antibiotic resistance in clinical isolates, and high carriage rates reported in children are cause for concern. Virtually all Moraxella catarrhalis isolates are resistant to β-lactam antibiotics, which are generally the first antibiotics prescribed to treat otitis media in children. The enzymes responsible for this resistance, BRO-1 and BRO-2, are lipoproteins and the mechanism by which they are secreted to the periplasm of M. catarrhalis cells has not been described.

Results

Comparative genomic analyses identified M. catarrhalis gene products resembling the TatA, TatB, and TatC proteins of the well-characterized Twin Arginine Translocation (TAT) secretory apparatus. Mutations in the M. catarrhalis tatA, tatB and tatC genes revealed that the proteins are necessary for optimal growth and resistance to β-lactams. Site-directed mutagenesis was used to replace highly-conserved twin arginine residues in the predicted signal sequence of M. catarrhalis strain O35E BRO-2, which abolished resistance to the β-lactam antibiotic carbanecillin.

Conclusions

Moraxella catarrhalis possesses a TAT secretory apparatus, which plays a key role in growth of the organism and is necessary for secretion of BRO-2 into the periplasm where the enzyme can protect the peptidoglycan cell wall from the antimicrobial activity of β-lactam antibiotics.

Utility of brief questionnaires of health-related quality of life (Airways Questionnaire 20 and Clinical COPD Questionnaire) to predict exacerbations in patients with asthma and COPD

BACKGROUND

There is some evidence that quality of life measured by long disease-specific questionnaires may predict exacerbations in asthma and COPD, however brief quality of life tools, such as the Airways Questionnaire 20 (AQ20) or the Clinical COPD Questionnaire (CCQ), have not yet been evaluated as predictors of hospital exacerbations.

OBJECTIVES

To determine the ability of brief specific health-related quality of life (HRQoL) questionnaires (AQ20 and CCQ) to predict emergency department visits (ED) and hospitalizations in patients with asthma and COPD, and to compare them to longer disease-specific questionnaires, such as the St George´s Respiratory Questionnaire (SGRQ), the Chronic Respiratory Disease Questionnaire (CRQ) and the Asthma Quality of Life Questionnaire (AQLQ).

METHODS

We conducted a two-year prospective cohort study of 208 adult patients (108 asthma, 100 COPD). Baseline sociodemographic, clinical, functional and psychological variables were assessed. All patients completed the AQ20 and the SGRQ. COPD patients also completed the CCQ and the CRQ, while asthmatic patients completed the AQLQ. We registered all exacerbations that required ED or hospitalizations in the follow-up period. Differences between groups (zero ED visits or hospitalizations versus ≥ 1 ED visits or hospitalizations) were tested with Pearson´s X(2) or Fisher´s exact test for categorical variables, ANOVA for normally distributed continuous variables, and Mann-Whitney U test for non-normally distributed variables. Logistic regression analyses were performed to estimate the predictive ability of each HRQoL questionnaire.

RESULTS

In the first year of follow-up, the AQ20 scores predicted both ED visits (OR: 1.19; p = .004; AUC 0.723) and hospitalizations (OR: 1.21; p = .04; AUC 0.759) for asthma patients, and the CCQ emerged as independent predictor of ED visits in COPD patients (OR: 1.06; p = .036; AUC 0.651), after adjusting for sociodemographic, clinical, and psychological variables. Among the longer disease-specific questionnaires, only the AQLQ emerged as predictor of ED visits in asthma patients (OR: 0.9; p = .002; AUC 0.727). In the second year of follow-up, none of HRQoL questionnaires predicted exacerbations.

CONCLUSIONS

AQ20 predicts exacerbations in asthma and CCQ predicts ED visits in COPD in the first year of follow-up. Their predictive ability is similar to or even higher than that of longer disease-specific questionnaires.

Costs of chronic obstructive pulmonary disease in relation to compliance with guidelines: a study in the primary care setting

BACKGROUND

The aim of this study was to analyse the economic impact of nonadherence to the Global Initiative for Obstructive Lung Disease (GOLD) guidelines in patients with chronic obstructive pulmonary disease (COPD).

METHODS

A retrospective analysis was carried out on a claim database. Patients aged at least 40 years with a diagnosis of COPD were eligible for this analysis. Demographics, medical data and use of resources were collected and direct and indirect costs were analysed (from January 2008 to June 2009). A probabilistic multivariate sensitivity analysis of avoided costs was carried out. All results are presented in annualized form and costs are expressed in Euros (2009).

RESULTS

A total of 1365 patients were included, 79.5% were men. The mean age (±standard deviation) was 71.4 (±10.3) years, the mean forced expiratory volume in 1 s (FEV1) was 65.3% and they had a COPD history of 5.5 (±2.9) years. Patients were divided into an adherent group and a nonadherent group depending on whether therapeutic recommendations according to severity defined in the GOLD guidelines (2007) were followed. Patients in both groups were also classified as having stage II (FEV1 < 80% and < 50%) or stage III disease (FEV1 < 50% and ≥ 30%). The total annual drug cost per patient in the nonadherent group was €771.5 while it was only €426.4 for the adherent group. The average direct cost per patient per year in the nonadherent stage II group was €1465 (±971) and it rose to €2942 (±1918) for patients in the nonadherent group with stage III disease. The potential saving from the implementation of the GOLD guidelines in stage II COPD amounted to €758 per patient per year (68% saving on drug cost). In contrast, the cost for patients with stage III disease was higher in the adherent group versus the nonadherent group (€2468).

CONCLUSIONS

The cost of COPD may vary according to compliance with the GOLD guidelines. The cost observed for patients with stage II disease is higher than expected in patients who adhere to treatment, but patients with stage III disease treated according to the GOLD guidelines had significantly higher treatment costs.

Cigarette smoke exposure as a model of inflammation associated with COPD

Chronic obstructive pulmonary disease (COPD) is characterized by progressive airflow limitation resulting from inflammation-driven pathologies in the lungs that are a consequence of smoking over many years. Given that the disease is increasing globally, understanding the mechanism by which cigarette smoke (CS) causes lung inflammation and exploiting that knowledge to develop effective treatments is urgently required. Animal models of CS exposure are commonly used to examine the inflammatory processes that may be involved in the development of COPD. The protocols described in this unit detail the development of preclinical models of CS-driven lung inflammation. These systems can be utilized to investigate the role of various biological pathways in CS-mediated inflammation and to assess the efficacy of new therapeutic strategies for treating COPD.

Improving clinical reality in chronic obstructive pulmonary disease economic modelling : development and validation of a micro-simulation approach

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a progressive and irreversible disease responsible for the deaths of 3 million people worldwide in 2005, and predicted to be the third leading cause of death worldwide by 2030. Many COPD models developed to date have followed a Markov structure, in which patients or populations can move between defined health states over successive time periods or cycles. In COPD, health states are typically based on disease severity defined solely by lung function, as described by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines. These current modelling methods may restrict the ability to reflect the disease progression/clinical pathway or clinical practice.

OBJECTIVES

Given these limitations in previous COPD models, the authors aimed to develop a more flexible model that could improve on the description of the clinical disease pathway. The overall objective of this model was to inform the development of policies, guidelines or cost-effectiveness analyses. A second objective was to validate the model in relation to existing epidemiology studies of COPD.

METHODS

A patient simulation model was developed in Microsoft Excel™. The predictability of the model was tested by populating it with data from natural history of disease studies as well as with clinical trial data. Each patient moves through the model with demographic characteristics randomly generated from a set distribution. These characteristics determine the risk of clinical events occurring in the model.

RESULTS

The validation with these studies found the model to have generally good predictive ability, yielding in this way a good degree of external validity.

CONCLUSIONS

The micro-simulation model is a flexible approach for modelling COPD that allows consideration of complex COPD treatment pathways. The model was found to be generally robust in terms of predicting clinical outcomes of published studies when tested against other studies. It has significant potential as a tool for supporting future COPD treatment positioning decisions as well as to inform the development of policies, guidelines or cost-effectiveness analyses.

Healthcare utilization and costs among chronic bronchitis patients treated with maintenance medications from a US managed care population

OBJECTIVES

This study aimed to examine the real-world healthcare resource utilization (HCRU) and direct costs among chronic bronchitis (CB) patients treated with chronic obstructive pulmonary disease (COPD) maintenance medications.

METHODS

This retrospective analysis utilized administrative claims data from 14 US commercial managed care plans. Eligible patients were ≥40 years old, had ≥2 years of continuous enrollment, ≥1 CB (ICD-9-CM code 491.xx) hospitalization or emergency department (ED) visit or ≥2 office visits between 1/1/2004 and 5/31/2011, and had ≥2 pharmacy fills for COPD medications during follow-up (first fill served as the index date). All-cause and COPD-related HCRU and costs were assessed during follow-up. Multivariate models were utilized to identify predictors of total costs.

RESULTS

Treated CB patients (n = 17,382; 50.6% female; mean age 66.7 (SD = 11.4) years) had a mean of 7.6 (SD = 6.3) COPD maintenance medication fills during follow-up. Overall, 32.6% of patients had ≥1 COPD-related inpatient hospitalizations, 12.9% had ≥1 ED visit, and 81.8% had ≥1 office visit. Mean all-cause and COPD-related total costs were $25,747 (SD = $51,105) and $12,609 (SD = $36,801), respectively, during follow-up. Among the sub-group with ≥1 exacerbation during baseline year, 42.3% had ≥1 COPD-related inpatient hospitalization, 18.5% had ≥1 ED visit, and 88.2% had ≥1 office visit. Mean follow-up all-cause and COPD-related total costs were $29,861 (SD = $49,799) and $16,784 (SD = $34,170), respectively. The number of baseline exacerbations was a significant predictor of all-cause and COPD-related total costs during follow-up.

LIMITATIONS

This study lacked standard measures of CB severity; however, severity proxies were utilized.

CONCLUSION

HCRU and costs among CB patients were substantial during follow-up, despite treatment with COPD maintenance medications. Additional interventions aiming to prevent or reduce HCRU and costs among CB patients warrant exploration.

Mean Platelet Volume and Platelet Distribution Width in Patients With Chronic Obstructive Pulmonary Disease

We evaluated mean platelet volume (MPV; an indicator of vascular risk) and platelet distribution width in patients with stable chronic obstructive pulmonary disease (COPD; n = 85). We also included a control group of 34 smokers without airflow limitation. Mean platelet volume was significantly higher in patients with COPD (10.69 ± 1.0 vs 9.96 ± 1.10 fL, P < .001) than in the smoker controls. White blood cell (WBC) count was also significantly higher in patients with COPD than in the smoker controls (10 642 ± 1247 vs 7136 ± 1887/μL, P < .001). There was a correlation between MPV and WBC in patients with COPD, especially in those at stage III ( r = .530, P = .004) and IV ( r = .389, P = .023). Mean platelet volume did not correlate with any indices of COPD severity. In patients with COPD, MPV and WBC levels are higher than those of smokers with normal pulmonary function and are significantly correlated. Whether these effects relate to vascular risk in patients with COPD remain to be established.

The importance of understanding epidemiology in order to inform financial decisions: a lesson from the Scottish Home Oxygen Service

OBJECTIVES

To ensure that decisions on the future planning of the Scottish Home Oxygen Service reflect population needs by examining the epidemiology of the main conditions that require home oxygen therapy and trends in their management.

STUDY DESIGN

Analysis of routinely available vital event and health service data supplemented by published literature. Use of linked data to provide person-based analyses.

METHODS

Consideration of trends in key risk factors, disease incidence, prevalence and mortality for chronic neonatal lung disease, cystic fibrosis, chronic interstitial lung disease in adults and chronic obstructive pulmonary disease. Examination of trends in management of these conditions including hospital admissions, length of stay and re-admissions.

RESULTS

The prevalence of all the conditions studied has increased in Scotland over recent years due to a combination of increased incidence, increased survival, more active case finding and demographic changes. There have been changes in management with trends towards shorter hospital stays.

CONCLUSIONS

The clinical need for home oxygen therapy is likely to continue to increase over the next 10-20 years. It will encompass all age groups and a complex range of conditions. Public health needs to be proactive in providing relevant needs assessment information to ensure that planning within financial constraints is appropriately informed on population needs.

Factors influencing the length of hospital stay among patients resident in Blackpool admitted with COPD: a cross-sectional study

OBJECTIVES

To identify the differential effects of patient, health service, temporal and geographic factors on length of stay (LOS) for chronic obstructive pulmonary disease (COPD)-related admissions.

DESIGN

We used stratified Cox proportional hazard model to evaluate the association between LOS and patient, health service, temporal and geographical factors.

SETTING

Patients resident in Blackpool, North West England, admitted to the local hospital with COPD.

PARTICIPANTS

We used the Admitted Patient Care General Episode Commissioning Dataset for the period 1 April 2005-31 March 2010. We analysed records of admission spells among patients resident in Blackpool aged 40 years or older admitted with a primary diagnosis of COPD.

RESULTS

There were 2410 admissions meeting the inclusion criteria over the period. These admissions were attributed to 1172 COPD patients, an average of 2.06 admissions per patient. The median LOS was 6 days (95% CI 6 to 6) while the mean was 9.8 days (95% CI 9.1 to 10.5). Patients were 22% more likely to be discharged earlier in 2009/2010 compared with 2005/2006 (adjusted HR 1.22; p=0.0100). LOS was associated with socioeconomic deprivation with those in the most deprived areas being 35% less likely to be discharged earlier compared with those from the least deprived areas (adjusted HR 0.65; p=0.0010).

CONCLUSIONS

LOS among COPD patients have reduced over the period of the study. Age, deprivation, Charlson index, specialty of admission and cause of exacerbations were independently associated with LOS. Though there were no significant associations between LOS and season of admission and distance from hospital, there were significant variations in LOS associated with these variables based on selected patient characteristics.

[Prevention of COPD exacerbation: a fundamental challenge]

INTRODUCTION

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are a cause of suffering for patients and a burden for healthcare systems and society. Their prevention represents individual and collective challenge. The present article is based on the work of a group of experts who met on 5th and 6th May 2011 and seeks to highlight the importance of AECOPD.

STATE OF THE ART

In the absence of easily quantifiable criteria, the definition of AECOPD varies in the literature, making identification difficult and affecting interpretation of study results. Exacerbations increase mortality and risk of cardiovascular disease. They also increase the risk of developing further exacerbations, accelerate the decline in lung function and contribute to reduction in muscle mass. By limiting physical activity and affecting mental state (anxiety, depression), AECOPD are disabling and impair quality of life. They increase work absenteeism and are responsible for about 60% of the global cost of COPD.

PERSPECTIVES

Earlier identification with simple criteria, possibly associated to patient phenotyping, could be helpful in preventing hospitalization.

CONCLUSIONS

Given their immediate and delayed impact, AECOPD should not be trivialized or neglected. Their prevention is a fundamental issue.

Clinical factors affecting the direct cost of patients hospitalized with acute exacerbation of chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a disease of increasing significance in terms of economic and social burden due to its increasing prevalence and high costs. Direct costs of COPD are mostly associated with hospitalization expenditures. In this study, our objective was to investigate the costs of hospitalization and factors affecting these costs in patients hospitalized due to acute exacerbation of COPD (AECOPD).

METHODS

A total of 284 patients hospitalized AECOPD were included in the study. Data were examined retrospectively using the electronic hospital charts.

RESULTS

Mean duration of hospitalization was 11.38 ± 6.94 days among study patients. Rates of admission to the intensive care unit, initiation of non-invasive mechanical ventilation (NIMV) and invasive mechanical ventilation (MIV) were 37.3% (n=106), 44.4% (n=126) and 18.3% (n=52) respectively. The rate of mortality was 14.8% (n=42). Mean cost of a single patient hospitalized for an AECOPD was calculated as $1765 ± 2139. Mean cost of admission was $889 ± 533 in standard ward, and $2508 ± 2857 in intensive care unit (ICU). The duration of hospitalization, a FEV1% predicted value below 30%, having smoked 40 package-years or more, the number of co-morbidities, NIMV, IMV, ICU, exitus and the number of hospitalizations in the past year were among the factors that increased costs significantly. Hospital acquired pneumonia, chronic renal failure and anemia also increased the costs of COPD significantly.

CONCLUSION

The costs of treatment increase with the severity of COPD or with progression to a higher stage. Efforts and expenditures aimed at preventing COPD exacerbations might decrease the costs in COPD.

The effects of respiratory training for chronic obstructive pulmonary disease patients: a randomised clinical trial

AIMS AND OBJECTIVES

To assess the effects of respiratory training on lung function, activity tolerance and quality of life in patients with chronic obstructive pulmonary disease.

BACKGROUND

For patients with chronic obstructive pulmonary disease, pulmonary rehabilitation can increase activity tolerance and improve their psychological state by relieving dyspnoea and promoting their quality of life.

DESIGN

A randomised clinical trial was conducted in a local hospital.

METHODS

Patients with chronic obstructive pulmonary disease were randomly assigned to intervention (n=20) and control groups (n=20). Spirometry, six-minute walking distance and quality of life were used to assess the efficacy of respiratory training programme.

RESULTS

Significant improvement in lung function, including forced vital capacity (p=0.037), forced expiratory volume in one-second (p=0.006) and per cent predicted forced expiratory volume in one-second (p=0.008) in the intervention group. Regarding efficacy of the training programme for patients with chronic obstructive pulmonary disease, in forced expiratory volume in one-second (p=0.024) and per cent predicted forced expiratory volume in one-second (p=0.035), six-minute walking distance significantly increased. In addition, there were significant improvements for symptoms (p=0.018), impact (p<0.001) and total quality of life scores (p<0.001), as well as significantly decreased body mass, airflow obstruction, dyspnoea and exercise capacity index (p=0.004) in the intervention group.

CONCLUSIONS

A respiratory training programme for patients with chronic obstructive pulmonary disease was found to relieve dyspnoea, maintain lung function, increase activity tolerance and improve quality of life.

RELEVANCE TO CLINICAL PRACTICE

Respiratory training programme can be used as a routine rehabilitation protocol for patients with chronic obstructive pulmonary disease and can be used by nurses as a reference to monitor chronic obstructive pulmonary disease patients' health status.

Airway bacterial colonization: the missing link between COPD and cardiovascular events?

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death worldwide and, according to the World Health Organization, its prevalence will double by 2020. COPD is a chronic inflammatory disease of the lung characterized by poorly reversible airflow limitation and, frequently, by extrapulmonary manifestations. In particular, the cardiovascular manifestations are responsible for high morbidity and mortality.

METHODS AND RESULTS

A systematic literature search was performed of studies published in Medline until December 2010, using the key-words: COPD, bacterial colonization, COPD exacerbation, atherosclerosis, systemic inflammation, cardiovascular event and risk factors. In addition to the studies identified in the primary search, reference lists of included articles were analyzed for additional papers related to the topic. The pathogenetic mechanisms underlying atherosclerosis - namely inflammation, oxidative stress and endothelial dysfunction - are in common with COPD. Moreover, they are increased in the presence of COPD, especially in patients who present airway bacterial colonization, increased rate of exacerbations and elevated levels of both airway and systemic inflammation.

CONCLUSION

COPD is associated with an increased burden of atherosclerotic disease. Systemic inflammation and oxidative stress play key roles in this association. COPD patients with airway bacterial colonization, as compared to patients without airway colonization, generally present more frequent exacerbations and higher levels of both airway and systemic inflammation. This COPD subgroup should be considered at particularly increased risk of developing cardiovascular complications and receive more attention concerning diagnosis, treatment, prevention and research.

Beta defensin-2 is reduced in central but not in distal airways of smoker COPD patients

Background

Altered pulmonary defenses in chronic obstructive pulmonary disease (COPD) may promote distal airways bacterial colonization. The expression/activation of Toll Like receptors (TLR) and beta 2 defensin (HBD2) release by epithelial cells crucially affect pulmonary defence mechanisms.

Methods

The epithelial expression of TLR4 and of HBD2 was assessed in surgical specimens from current smokers COPD (s-COPD; n = 17), ex-smokers COPD (ex-s-COPD; n = 8), smokers without COPD (S; n = 12), and from non-smoker non-COPD subjects (C; n = 13).

Results

In distal airways, s-COPD highly expressed TLR4 and HBD2. In central airways, S and s-COPD showed increased TLR4 expression. Lower HBD2 expression was observed in central airways of s-COPD when compared to S and to ex-s-COPD. s-COPD had a reduced HBD2 gene expression as demonstrated by real-time PCR on micro-dissected bronchial epithelial cells. Furthermore, HBD2 expression positively correlated with FEV1/FVC ratio and inversely correlated with the cigarette smoke exposure. In a bronchial epithelial cell line (16 HBE) IL-1β significantly induced the HBD2 mRNA expression and cigarette smoke extracts significantly counteracted this IL-1 mediated effect reducing both the activation of NFkB pathway and the interaction between NFkB and HBD2 promoter.

Conclusions

This study provides new insights on the possible mechanisms involved in the alteration of innate immunity mechanisms in COPD.

Acute exacerbations of COPD in the United States: inpatient burden and predictors of costs and mortality

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are a leading cause of hospitalizations in the United States and the major cost driver of COPD. This study determined the national inpatient burden of AECOPD and assessed the association of co-morbidities and hospital characteristics with inpatient costs and mortality. Discharge records from the Agency for Healthcare Research and Quality (AHRQ) Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample for 2006 was utilized. Outcomes of costs and mortality were assessed for AECOPD hospitalizations in cases ≥40 years of age. Multivariate regression analyses using a generalized linear model framework were conducted to determine predictors of inpatient costs and mortality controlling for patient demographics, primary payer, co-morbidity index, length of stay, hospital region, mechanical ventilation, and admission period. Overall, 1,254,703 hospitalizations for AECOPD were observed with mean costs of $9545(±12,700) and total costs of $11.9 billion. In-hospital mortality was 4.3% (N = 53,748). Discharges averaged 70.6 (±11.9) years of age. The majority were female (52.8%) and of white race (83.6% of reported race). Several co-morbidities were significantly associated with both costs and mortality (p < 0.001): acute myocardial infarction; congestive heart failure; cerebrovascular disease; lung cancer; cardiac arrhythmias; pulmonary circulation disorders; and weight loss. Significantly higher costs (p < 0.001) were associated with large and urban hospitals. The importance of co-morbidities in AECOPD is indicated in their association with prognosis and inpatient costs. Future research should determine if better management of these conditions can favorably impact the COPD disease burden.

Efficacy evaluation of educational sessions for patients with asthma and COPD

INTRODUCTION

Asthma and COPD are respiratory diseases in which a better knowledge and understanding of the pathology allows the patients to be more involved, which is crucial in their treatment. Holding educational sessions is a good way of imparting information to the patients.

AIM

To determine the efficacy of educational sessions in helping patients with Asthma and COPD to acquire a better understanding of their condition.

METHODS

Following a Portuguese Lung Foundation initiative to improve knowledge about respiratory health, educational sessions for patients suffering from Asthma or COPD were organized. 25 randomized patients with the disease were invited to participate. Each session lasted 60 minutes. Patient knowledge was tested by means of a multiple choice questionnaire before and after the session.

RESULTS

Fifteen patients with asthma attended the sessions, they had an average age of 36 years, of which 60% were female. Within the group 60% were able to name their pathology correctly. Seventeen patients with COPD attended the sessions, they had an average age of 69 years, of which 70% were males and only 3 (17,6%) patients were able to correctly name their pathology. In both groups, there was a statistically positive improvement (p<0,05) of correct answers to the questionnaire the end of each educational session.

CONCLUSION

Patient knowledge increased in each educational session. Patients with COPD were less well informed about their disease than patients with asthma and they also had more difficulty in correctly naming their disease.

Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease

BACKGROUND

Pulmonary rehabilitation has become a cornerstone in the management of patients with stable Chronic Obstructive Pulmonary Disease (COPD). Systematic reviews have shown large and important clinical effects of pulmonary rehabilitation in these patients. However, in unstable COPD patients who have recently suffered an exacerbation, the effects of pulmonary rehabilitation are less established.

OBJECTIVES

To assess the effects of pulmonary rehabilitation after COPD exacerbations on future hospital admissions (primary outcome) and other patient-important outcomes (mortality, health-related quality of life and exercise capacity).

SEARCH STRATEGY

Trials were identified from searches of CENTRAL, MEDLINE, EMBASE, PEDRO and the Cochrane Airways Group Register of Trials. Searches were current as of March 2010.

SELECTION CRITERIA

Randomized controlled trials comparing pulmonary rehabilitation of any duration after exacerbation of COPD with conventional care. Pulmonary rehabilitation programmes needed to include at least physical exercise. Control groups received conventional community care without rehabilitation.

DATA COLLECTION AND ANALYSIS

We calculated pooled odds ratios and weighted mean differences (MD) using random-effects models. We requested missing data from the authors of the primary studies.

MAIN RESULTS

We identified nine trials involving 432 patients. Pulmonary rehabilitation significantly reduced hospital admissions (pooled odds ratio 0.22 [95% CI 0.08 to 0.58], number needed to treat (NNT) 4 [95% CI 3 to 8], over 25 weeks) and mortality (OR 0.28; 95% CI 0.10 to 0.84), NNT 6 [95% CI 5 to 30] over 107 weeks). Effects of pulmonary rehabilitation on health-related quality of life were well above the minimal important difference when measured by the Chronic Respiratory Questionnaire (MD for dyspnea, fatigue, emotional function and mastery domains between 0.81 (fatigue; 95% CI 0.16 to 1.45) and 0.97 (dyspnea; 95% CI 0.35 to 1.58)) and the St. Georges Respiratory Questionnaire total score (MD -9.88; 95% CI -14.40 to -5.37); impacts domain (MD -13.94; 95% CI -20.37 to -7.51) and for activity limitation domain (MD -9.94; 95% CI -15.98 to -3.89)). The symptoms domain of the St. Georges Respiratory Questionnaire showed no significant improvement. Pulmonary rehabilitation significantly improved exercise capacity and the improvement was above the minimally important difference (six-minute walk test (MD 77.70 meters; 95% CI 12.21 to 143.20) and shuttle walk test (MD 64.35; 95% CI 41.28 to 87.43)). No adverse events were reported in three studies.

AUTHORS' CONCLUSIONS

Evidence from nine small studies of moderate methodological quality, suggests that pulmonary rehabilitation is a highly effective and safe intervention to reduce hospital admissions and mortality and to improve health-related quality of life in COPD patients who have recently suffered an exacerbation of COPD.

Il percorso diagnostico-assistenziale della broncopneumopatia cronica ostruttiva riacutizzata in Medicina Interna

Introduction

Chronic obstructive pulmonary disease (COPD) is the second leading cause of hospitalization in Internal Medicine departments in Italy and the fourth leading cause of death all over the word. By 2020, COPD will be the third leading cause of death and the fifth leading cause of disability. It is – along with chronic congestive heart failure – one of the most common causes of unscheduled hospital readmissions, and as such it represents a significant economic burden for the health-care system. Exacerbations of COPD are important events in the natural history of this prevalent condition.

Discussion

This review provides a comprehensive state-of-the-art look at prevention and management of COPD exacerbations. Treatment of these episodes has to be tailored to the severity of the clinical presentation. We now have a wide range of therapeutic available options, based on the results of clinical trials. Management of the acute event should include the necessary measures (mainly the administration of inhaled short-acting bronchodilators, inhaled or oral corticosteroids, and antibiotics), with or without oxygen and ventilator support.

Conclusions

To improve the management of COPD exacerbations, the focus of care must be shifted from the episodic acute complications to their systematic prevention. The management of COPD, which is often associated with multiple co-morbidities, is complex and requires a tailored, multifaceted and multidisciplinary approach. Integrated care for COPD also requires that patients be informed about their condition, that they participate actively in their care, and that they have easy access to the necessary health-care services.

Risk factors of hospitalization and readmission of patients with COPD in Hong Kong population: analysis of hospital admission records

BACKGROUND

Chronic Obstructive Pulmonary Disease (COPD) accounts for around 4% of all public hospital annual admissions in Hong Kong. By year 2020, COPD will be ranked fifth among the conditions with the highest burden to the society. This study identifies admission and unplanned readmission of COPD patients, factors affecting unplanned readmission, and estimates its cost burden on the public healthcare system in Hong Kong.

METHODS

This is a retrospective study analyzing COPD admissions to all public hospitals in Hong Kong. All admission episodes to acute medical wards with the principal diagnosis of COPD (ICD-9:490-492, 494-496) from January 2006 to December 2007 were captured. Unplanned readmission was defined as an admission which followed a previous admission within 30 days.

RESULTS

In 2006 and 2007, 65497 (8.0%) of episodes from medical wards were identified as COPD admissions, and among these, 15882 (24.2%) were unplanned readmissions. The mean age of COPD patients was 76.81 ± 9.59 years and 77% were male. Unplanned readmission was significantly associated with male gender, receiving public assistance and living in nursing homes while no association was found with the Charlson comorbidity index. Patients who were readmitted unplanned had a significant longer acute length of stay (β = 0.3894, P < 0.001) after adjustment for other covariates.

CONCLUSIONS

Unplanned readmission of COPD patients has a huge impact on the public healthcare system. A systematic approach in programme provision and a good discharge planning process targeting on COPD patients who are at high risk of unplanned readmission are essential.

COPD uncovered: an international survey on the impact of chronic obstructive pulmonary disease [COPD] on a working age population

BACKGROUND

Approximately 210 million people are estimated to have chronic obstructive pulmonary disease [COPD] worldwide. The burden of disease is known to be high, though less is known about those of a younger age. The aim of this study was to investigate the wider personal, economic and societal burden of COPD on a cross country working-age cohort.

METHODS

A cross-country [Brazil, China, Germany, Turkey, US, UK] cross-sectional survey methodology was utilised to answer the research questions. 2426 participants aged 45-67 recruited via a number of recruitment methods specific to each country completed the full survey. Inclusion criteria were a recalled physician diagnosis of COPD, a smoking history of > 10 pack years and the use of COPD medications in the previous 3 months prior to questioning. The survey included items from the validated Work Productivity and Activity Impairment [WPAI] scale and the EuroQoL 5 Dimension [EQ-5D] scale. Disease severity was measured using the 5-point MRC [Medical Research Council] dyspnoea scale as a surrogate measure.

RESULTS

64% had either moderate [n = 1012] or severe [n = 521] COPD, although this varied by country. 75% of the cohort reported at least one comorbid condition. Quality of life declined with severity of illness [mild, mean EQ-5D score = 0.84; moderate 0.58; severe 0.41]. The annual cost of healthcare utilisation [excluding treatment costs and diagnostic tests] per individual was estimated to be $2,364 [£1,500]. For those remaining in active employment [n: 677]: lost time from work cost the individual an average of $880 [£556] per annum and lifetime losses of $7,365 [£4,661] amounting to $596,000 [£377,000] for the cohort. 447 [~40%] of the working population had retired prematurely because of COPD incurring individual estimated lifetime income losses of $316,000 [£200,000] or a combined total of $141 m [£89.6 m]. As the mean age of retirees was 58.3 and average time since retirement was 4 years, this suggests the average age of retirement is around 54. This would mean a high societal and economic impact in all study countries, particularly where typical state retirement ages are higher, for example in Brazil, Germany and the UK [65] and the US [65,66,67], compared to Turkey [58 for women, 60 for men] and China [60].

CONCLUSIONS

Although generalisation across a broader COPD population is limited due to the varied participant recruitment methods, these data nevertheless suggest that COPD has significant personal, economic and societal burden on working age people. Further efforts to improve COPD diagnosis and management are required.

Review series: Examples of chronic care model: the home-based chronic care model: redesigning home health for high quality care delivery

Individuals with chronic obstructive pulmonary disease (COPD) face significant challenges due to frequent distressing dyspnea and deficits related to activities of daily living. Individuals with COPD are often hospitalized frequently for disease exacerbations, negatively impacting quality of life and healthcare expenditure burden. The home-based chronic care model (HBCCM) was designed to address the needs of patients with chronic diseases. This model facilitates the re-design of chronic care delivery within the home health sector by ensuring patient-centered evidence-based care. This HBCCM foundation is Dr. Edward Wagner s chronic care model and has four additional areas of focus: high touch delivery, theory-based self management, specialist oversight and the use of technology. This article will describe this model in detail and outline how model use for patients with COPD can bring value to stakeholders across the health care continuum.

Cost-utility analysis of a pharmacy-led self-management programme for patients with COPD

OBJECTIVE

To undertake a cost-utility analysis (CUA) of a pharmacy-led self-management programme for Chronic Obstructive Pulmonary Disease (COPD).

SETTING

A single outpatient COPD clinic at the Mater Hospital, Belfast, Northern Ireland between.

METHOD

CUA alongside a randomised control trial. The economic analysis used data from 127 COPD patients aged over 45 years, with an FEV1 of 30-80% of the predicted normal value. Participants received either a pharmacy-led education and self-management programme, or usual care. One year costs were estimated from the perspective of the National Health Service and Personal Social Services and quality-adjusted life years (QALYs) were calculated based on responses to the EQ-5D at baseline, 6 and 12 months.

MAIN OUTCOME MEASURE

Cost per QALY gained.

RESULTS

The mean differences in costs and effects between the self-management and education programme and usual care were -£671.59 (95 CI%: -£1,584.73 to -£68.14) and 0.065 (95% CI; 0.000-0.128). Thus the intervention was the dominant strategy as it was both less costly and more effective than usual care. The probability of the intervention being cost-effective was 95% at a threshold of £20,000/QALY gained. Sensitivity analyses indicated that conclusions were robust to variations in most of the key parameters.

CONCLUSION

The self-management and education programme was found to be highly cost-effective compared to usual care. Further research is required to establish what aspects of self-management and education programmes have the greatest impact on cost-effectiveness.

Cost-utility analysis of a pharmacy-led self-management programme for patients with COPD

OBJECTIVE

To undertake a cost-utility analysis (CUA) of a pharmacy-led self-management programme for Chronic Obstructive Pulmonary Disease (COPD).

SETTING

A single outpatient COPD clinic at the Mater Hospital, Belfast, Northern Ireland between.

METHOD

CUA alongside a randomised control trial. The economic analysis used data from 127 COPD patients aged over 45 years, with an FEV1 of 30-80% of the predicted normal value. Participants received either a pharmacy-led education and self-management programme, or usual care. One year costs were estimated from the perspective of the National Health Service and Personal Social Services and quality-adjusted life years (QALYs) were calculated based on responses to the EQ-5D at baseline, 6 and 12 months.

MAIN OUTCOME MEASURE

Cost per QALY gained.

RESULTS

The mean differences in costs and effects between the self-management and education programme and usual care were -£671.59 (95 CI%: -£1,584.73 to -£68.14) and 0.065 (95% CI; 0.000-0.128). Thus the intervention was the dominant strategy as it was both less costly and more effective than usual care. The probability of the intervention being cost-effective was 95% at a threshold of £20,000/QALY gained. Sensitivity analyses indicated that conclusions were robust to variations in most of the key parameters.

CONCLUSION

The self-management and education programme was found to be highly cost-effective compared to usual care. Further research is required to establish what aspects of self-management and education programmes have the greatest impact on cost-effectiveness.

The cost of COPD exacerbations: a university hospital--based study in Greece

BACKGROUND

Hospitalization attributed to severe exacerbations is the major cost driver of Chronic Obstructive Pulmonary Disease (COPD). Given that in Greece no previous studies have addressed the economic burden of COPD, the aim of the study was to examine the hospitalization cost of COPD patients with severe exacerbations in the region of Thrace.

METHODS

Sample consisted of 142 COPD patients with severe exacerbations who were admitted to the pneumonology department of the University Teaching Hospital of Alexandroupolis (UTHA) in 2006 and 2007. Data collection was performed retrospectively and resource utilization was derived from patients' files. General Linear Model univariate analysis was applied in order to test the influence of disease severity on costs.

RESULTS

Mean actual cost per severe exacerbation was €1711; the amount of €621 is reimbursed by social security funds. Price discrepancies are observed between the actual and the nominal cost per patient in all disease stage categories. Mean hospitalization cost per COPD patient increases slightly with the severity of the disease. However, in the very severe stage it greatly increases mainly due to Intensive Care Unit (ICU) admission. In multivariate analysis the length of stay and the stage of the disease were both related to significantly increased costs, while the existence of co-morbidities exhibited marginal significant relation to increased cost.

CONCLUSIONS

The cost estimation of severe exacerbations is important as it could trigger further research and also provide the opportunity of creating national epidemiological and economic data. Such data could contribute to the estimation of the total economic and societal burden of COPD in the country.

Nurse tele-consultations with discharged COPD patients reduce early readmissions--an interventional study

INTRODUCTION

Exacerbations of chronic obstructive pulmonary disease (ECOPD) are the most common cause for admissions and readmissions to medical wards worldwide.

OBJECTIVES

To investigate the effect on early readmissions of telemedicine video consultations (TVCs) between respiratory nurses placed at the hospital and COPD patients in their homes after a discharge from the hospital, which was caused by ECOPD.

METHODS

This study was an interventional study in which all ECOPD were consecutively allocated into two groups (TVC or control) depending on their home municipality. The patient received daily TVC at home with a nurse based at the hospital for approximately one week. Thereafter, the patient received at least one follow-up call and they could call the nurse for the rest of the study period of 28 days. The telemedicine equipment was composed of a computer with a web camera, a microphone and measurement equipment.

RESULTS

Within each of the two groups, TVC (n = 50) and control (n = 50), 12% and 22%, respectively, were readmitted [differences between rates -10% (95% confidence interval -25;5)] because of ECOPD. The multivariate Cox regression model showed the TVC assignment as a significant protective factor for early readmission [hazard ratio (HR) 0.25 (0.09-0.69)]. High age [HR 3.94 (1.46-10.6)] and male gender [HR 2.97 (0.99-8.97)] were associated with high hazard. Patient satisfaction was high.

CONCLUSIONS

In a hospitalised population with ECOPD, a nurse TVC assignment is protective against early readmission and reduces the days of readmission.

The validity of using ICD-9 codes and pharmacy records to identify patients with chronic obstructive pulmonary disease

Background

Administrative data is often used to identify patients with chronic obstructive pulmonary disease (COPD), yet the validity of this approach is unclear. We sought to develop a predictive model utilizing administrative data to accurately identify patients with COPD.

Methods

Sequential logistic regression models were constructed using 9573 patients with postbronchodilator spirometry at two Veterans Affairs medical centers (2003-2007). COPD was defined as: 1) FEV1/FVC <0.70, and 2) FEV1/FVC < lower limits of normal. Model inputs included age, outpatient or inpatient COPD-related ICD-9 codes, and the number of metered does inhalers (MDI) prescribed over the one year prior to and one year post spirometry. Model performance was assessed using standard criteria.

Results

4564 of 9573 patients (47.7%) had an FEV1/FVC < 0.70. The presence of ≥1 outpatient COPD visit had a sensitivity of 76% and specificity of 67%; the AUC was 0.75 (95% CI 0.74-0.76). Adding the use of albuterol MDI increased the AUC of this model to 0.76 (95% CI 0.75-0.77) while the addition of ipratropium bromide MDI increased the AUC to 0.77 (95% CI 0.76-0.78). The best performing model included: ≥6 albuterol MDI, ≥3 ipratropium MDI, ≥1 outpatient ICD-9 code, ≥1 inpatient ICD-9 code, and age, achieving an AUC of 0.79 (95% CI 0.78-0.80).

Conclusion

Commonly used definitions of COPD in observational studies misclassify the majority of patients as having COPD. Using multiple diagnostic codes in combination with pharmacy data improves the ability to accurately identify patients with COPD.

The costs of hospitalization in patients with acute exacerbation of chronic obstructive pulmonary disease

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is a major public health problem. It imparts a substantial economic burden on individuals and society. Acute exacerbations are the main cause of hospital admissions and hospitalizations in patients with COPD in Turkey.

OBJECTIVES

We aimed to determine the costs of hospitalization in patients with acute exacerbations of COPD (AECOPD).

RESULTS

A total of 7832 (1556 women, 6276 men) patients were hospitalized due to acute exacerbations of COPD between 2005-2009 in the Samsun Chest Diseases and Thoracic Surgery Hospital, northern Turkey. The mean age was 64.6 ± 19.8 years old and median length of hospital stay was 14.8 ± 9.5 days. The mean cost per admission was US$718 ± 364. Drug costs accounted for the largest portion (53.5%) of the mean cost, followed by bed cost (19.6%). One hundred seventy-four (2.2%) of the total hospitalized patients with AECOPD died in hospital.

CONCLUSION

AECOPD continues to have both significant economic burden and high mortality rate.

Determinants of elevated healthcare utilization in patients with COPD

BACKGROUND

Chronic obstructive pulmonary disease (COPD) imparts a substantial economic burden on western health systems. Our objective was to analyze the determinants of elevated healthcare utilization among patients with COPD in a single-payer health system.

METHODS

Three-hundred eighty-nine adults with COPD were matched 1:3 to controls by age, gender and area of residency. Total healthcare cost 5 years prior recruitment and presence of comorbidities were obtained from a computerized database. Health related quality of life (HRQoL) indices were obtained using validated questionnaires among a subsample of 177 patients.

RESULTS

Healthcare utilization was 3.4-fold higher among COPD patients compared with controls (p < 0.001). The "most-costly" upper 25% of COPD patients (n = 98) consumed 63% of all costs. Multivariate analysis revealed that independent determinants of being in the "most costly" group were (OR; 95% CI): age-adjusted Charlson Comorbidity Index (1.09; 1.01-1.2), history of: myocardial infarct (2.87; 1.5-5.5), congestive heart failure (3.52; 1.9-6.4), mild liver disease (3.83; 1.3-11.2) and diabetes (2.02; 1.1-3.6). Bivariate analysis revealed that cost increased as HRQoL declined and severity of airflow obstruction increased but these were not independent determinants in a multivariate analysis.

CONCLUSION

Comorbidity burden determines elevated utilization for COPD patients. Decision makers should prioritize scarce health care resources to a better care management of the "most costly" patients.

Optimizing management of chronic obstructive pulmonary disease in the upcoming decade

Chronic obstructive pulmonary disease (COPD) is a leading cause of disability and mortality. Caring for patients with COPD, particularly those with advanced disease who experience frequent exacerbations, places a significant burden on health care budgets, and there is a global need to reduce the financial and personal burden of COPD. Evolving scientific evidence on the natural history and clinical course of COPD has fuelled a fundamental shift in our approach to the disease. The emergence of data highlighting the heterogeneity in rate of lung function decline has altered our perception of disease progression in COPD and our understanding of appropriate strategies for the management of stable disease. These data have demonstrated that early, effective, and prolonged bronchodilation has the potential to slow the rate of decline in lung function and to reduce the frequency of exacerbations that contribute to functional decline. The goals of therapy for COPD are no longer confined to controlling symptoms, reducing exacerbations, and maintaining quality of life, and slowing disease progression is now becoming an achievable aim. A challenge for the future will be to capitalize on these observations by improving the identification and diagnosis of patients with COPD early in the course of their disease, so that effective interventions can be introduced before the more advanced, disabling, and costly stages of the disease. Here we critically review emerging data that underpin the advances in our understanding of the clinical course and management of COPD, and evaluate both current and emerging pharmacologic options for effective maintenance treatment.

Incremental third-party costs associated with COPD exacerbations: a retrospective claims analysis

BACKGROUND

Exacerbations are a major contributor to the large burden of treating chronic obstructive pulmonary disease (COPD). Estimates of exacerbation costs in the United States are limited.

OBJECTIVE

To estimate incremental costs associated with COPD exacerbation, particularly severe exacerbation, in the United States.

METHODS

COPD patients with at least one exacerbation were identified in the Thomson Reuters MarketScan administrative claims database. A COPD exacerbation was defined as patient use of oral or parenteral corticosteroids on the same day or within 7 days following a claim with a COPD diagnosis. Severe exacerbation was further defined if the exacerbation was associated with hospitalization or death. Healthcare costs and exacerbations were evaluated at quarterly intervals starting from patients' first observed claim with COPD diagnostic code in the database. Incremental costs associated with exacerbation were estimated as cost differences between quarters with exacerbation and quarters without exacerbation.

RESULTS

A total of 2644,174 patient-quarters, derived from 228,978 COPD patients, were included in the analysis. The average patient was followed an average of 2.9 years. The mean total cost was $17,016 per patient-quarter with severe exacerbation, $6628 per patient-quarter with non-severe exacerbation, an average of $8726 per patient-quarters with any exacerbation compared to $4762 per patient-quarter with no exacerbation. After adjusting for patient demographics, the mean incremental total cost was $11,261 per patient-quarter with severe exacerbation, $1509 per patient-quarter for non-severe exacerbation, and $3439 per patient-quarter with any exacerbation compared with patient-quarters with no exacerbation.

LIMITATIONS

The method used for defining exacerbations does not capture mild exacerbations. Additional limitations exist due to the nature of claims data.

CONCLUSIONS

Exacerbations, especially severe ones, result in a significant economic burden for third-party payers. Effective management of COPD and prevention of exacerbations may lead to improved patient outcomes and reduction in total healthcare costs for long-term management of COPD.