Systematic review of humanistic and economic burden of symptomatic chronic obstructive pulmonary disease

Financial burden and physical and emotional quality of life in COPD, heart failure, and kidney failure

Patients with chronic and serious illnesses experience significant quality of life concerns. More research is needed to understand the impact of financial burden on patients with COPD, heart failure, and kidney failure. Patients with COPD, heart failure, or kidney failure completed a cross-sectional online survey using validated measures of financial burden (general financial strain as well as financial toxicity attributable to treatment), physical quality of life (symptom burden and perceived health), and emotional quality of life (anxiety, depression, and suicidal ideation). ANCOVA was used to examine whether financial strain and financial toxicity were associated with physical and emotional quality of life, while accounting for key covariates. Among 225 participants with COPD (n = 137), heart failure (n = 48), or kidney failure (n = 40), 62.2% reported general financial strain, with 34.7% experiencing financial toxicity attributable to treatments. Additionally, 68.9% rated their health as fair or poor, experiencing significant symptom burden including fatigue, dyspnea, and chest pain. Participants also reported clinically relevant levels of anxiety (55.1%), depression (52.0%), and suicidal ideation (21.8%). In the total sample, financial strain was associated with worse physical and emotional quality of life on all measures (all Ps < .001). Financial toxicity attributable to treatment was not associated with quality of life in the total sample or subsamples. Patients with COPD, heart failure, and kidney failure face significant financial, physical, and emotional burdens. Financial strain appears to undermine physical and emotional quality of life. Our study highlights the demand for interventions aimed at mitigating financial strain and toxicity experienced by individuals with chronic illnesses.

Clinical evaluation of ventilation mode on acute exacerbation of chronic obstructive pulmonary disease with respiratory failure

BACKGROUND

At present, understanding of the most effective ventilation methods for treating chronic obstructive pulmonary disease (COPD) patients experiencing acute worsening symptoms and respiratory failure remains relatively limited. This report analyzed the efficiency and side effects of various ventilation techniques used for individuals experiencing an acute COPD exacerbation.

AIM

To determine whether pressure-controlled ventilation (PCV) can lower peak airway pressures (PAPs) and reduce the incidence of barotrauma compared to volume-controlled ventilation (VCV), without compromising clinical outcomes and oxygenation parameters.

METHODS

We have evaluated 600 patients who were hospitalized due to a severe COPD exacerbation, with 400 receiving mechanical ventilation for the respiratory failure. The participants were divided into two different groups, who were administered either VCV or PCV, along with appropriate management. We thereafter observed patients' attributes, clinical factors, and laboratory, radiographic, and arterial blood gas evaluations at the start and during their stay in the intensive care unit (ICU). We have also employed appropriate statistical methods for the data analysis.

RESULTS

Both the VCV and PCV groups experienced significant enhancements in the respiratory rate, tidal volume, and arterial blood gas values during their time in the ICU. However, no significant distinctions were detected between the groups in terms of oxygenation indices (partial pressures of oxygen/raction of inspired oxygen ratio) and partial pressures of carbon dioxide improvements. There was no considerable disparity observed between the VCV and PCV groups in the hospital mortality (32% vs 28%, P = 0.53), the number of days of ICU stay [median interquartile range (IQR): 9 (6-14) d vs 8 (5-13) d, P = 0.41], or the duration of the mechanical ventilation [median (IQR): 6 (4-10) d vs 5 (3-9) d, P = 0.47]. The PCV group displayed lower PAPs compared to the VCV group (P < 0.05) from the beginning of mechanical ventilation until extubation or ICU departure. The occurrence of barotrauma was considerably lower in the PCV group in comparison to the VCV group (6% vs 16%, P = 0.03).

CONCLUSION

Both VCV and PCV were found to be effective in treating patients with acute COPD exacerbation. However, PCV was associated with lower PAPs and a significant decrease in barotrauma, thus indicating that it might be a safer ventilation method for this group of patients. However, further large-scale study is necessary to confirm these findings and to identify the best ventilation approach for patients experiencing an acute COPD exacerbation.

Adherence enhancing interventions for pharmacological and oxygen therapy in patients with COPD: protocol for a systematic review and component network meta-analyses

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is characterised by hyperinflation and expiratory airflow limitation due to long-term exposure to irritants. The variety and complexity of COPD treatment and the possible added comorbidities may make the patients find it difficult to cope with the required medications. That is why supporting patients' adherence is critical because not taking medications correctly increases the risk of complications and creates an additional financial burden. A range of interventions aiming to improve patient adherence were used, and most of them are complex since they involve a mix of elements. Furthermore, despite the variety of available tools, assessing adherence is challenging because clinicians usually do not get a concrete judgement if their patients followed their treatment plan reliably. We aim to evaluate the effectiveness of adherence-enhancing interventions for COPD patients, explore which intervention (component) works for which patients and check the factors influencing the implementation and participant responses.

METHODS

We will perform a comprehensive literature search (Medline, Embase, Cochrane Library, trial registries) without restrictions on language and publication status, and we will include all controlled studies investigating the effect of adherence-enhancing intervention on patients with COPD. We plan to involve COPD patients in the systematic review development through two patient interviews (one before and one after the systematic review). Two reviewers will perform the screening, data extraction and risk of bias (ROB) assessment. For ROB, we will use ROB 2.0 to assess randomised controlled trials, and ROBINS-I to assess non-randomised studies. We will perform pair-wise random-effects meta-analyses and component network meta-analyses to identify the most effective components and combinations of components. We will use the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach to assess the quality of evidence. To determine the degree of complexity, we will use the iCAT_SR checklist, and then, following a logical model, we will group the interventions according to prespecified criteria.

DISCUSSION

This systematic review aims to point out the most effective and implementable adherence-enhancing interventions by using methods for synthesising evidence on complex interventions and involving COPD patients all along with the review process.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022353977.

Prevalence, Causes, and Health Care Burden of Pleural Effusions Among Hospitalized Adults in China

This cross-sectional study investigates the estimated prevalence, common causes, and health care burden of pleural effusions among hospitalized adults in China.

Health-Related Quality of Life of People Living with COPD in a Semiurban Area of Western Nepal: A Community-Based Study

Chronic Obstructive Pulmonary Disease (COPD) is a major cause of morbidity and mortality in Nepal. It is a progressive lung disease and has a significant impact on the quality of life of patients. Health-related quality of life (HRQOL) reflects the health- and disease-related facets of quality of life. Limited studies have assessed the impact of COPD on HRQOL and associated factors in Nepal. This study is based on a cross-sectional household survey data from a semiurban area of Western Nepal. A validated Nepali version of St George's Respiratory Questionnaire (SGRQ) was used to measure the HRQOL. COPD was defined together with post-bronchodilator airflow obstruction and the presence of respiratory symptoms. Post-bronchodilator airflow obstruction was defined as Forced Expiratory Volume in 1st second (FEV₁) to Forced Vital Capacity (FVC) ratio < 0.70. COPD was diagnosed in 122 participants, and their median (IQR) total score of HRQOL was 40 (26 - 69); the score of symptoms, activity, and impact area were 53 (37 - 74), 57 (36 - 86), and 26 (13 - 62), respectively. The overall HRQOL was significantly different in terms of age, occupational status, physical activity, and comorbidities. Disease severity and the presence of respiratory symptoms had a significant difference in HRQOL (p = 0.0001). Appropriate measures to improve conditions and addressing the associated factors like respiratory symptoms and enhancing physical activity are necessary and important.

Effect of compliance with GOLD treatment recommendations on COPD health care resource utilization, cost, and exacerbations among patients with COPD on maintenance therapy

BACKGROUND: The Global Initiative for Chronic Obstructive Lung Disease (GOLD) report for the management of chronic obstructive pulmonary disease (COPD) focuses on reducing existing symptoms, decreasing the risk of future exacerbations, and improving health status by recommending specific drug therapy based on exacerbation risk and symptoms. However, disparities exist between evidence-based recommendations and clinical practice. Research that quantifies the real-world effect of COPD regimen alignment with the GOLD recommendations on clinical and economic outcomes is needed. OBJECTIVE: To compare COPD-related health care resource utilization (HRU) and costs, as well as exacerbation rates, among patients with COPD on maintenance therapy based on 2017 GOLD treatment recommendation compliance status per GOLD ABCD risk group classification in a U.S. commercially insured/Medicare Advantage population. METHODS: This retrospective cohort study utilized administrative claims data in the HealthCore Integrated Research Database. The COPD population was identified using a previously validated claims-based predictive model. Among this population, patients with ≥ 1 claim for a COPD maintenance medication (earliest maintenance fill-date = index date) between January 1, 2014, and March 31, 2017, were identified. Patients were required to be aged ≥ 40 years, have ≥ 12 months of pre-index and ≥ 30 days of post-index health plan enrollment, with no diagnosis for asthma, cystic fibrosis, and/or lung cancer at any time from January 1, 2013, to March 31, 2018. Patients were categorized into exacerbation risk/symptomatology groups according to the 2017 GOLD ABCD assessment recommendations and were then classified into treatment-compliance status based on their maintenance therapy. Multivariable analyses were conducted to examine post-index COPD-related HRU, costs, and exacerbations by compliance status. RESULTS: The primary analytical study sample included 38,382 patients in the GOLD A/B group and 6,525 in the GOLD C/D group. Patients were further categorized into GOLD A (n = 19,345), B (n = 19,037), C (n = 1,865), and D (n = 4,670). GOLD-compliant regimens were observed in 32.9% of patients in the GOLD A/B group and in 58.9% of patients in the GOLD C/D group. Inhaled corticosteroid-containing regimens were the most commonly observed noncompliant regimen. Patients on compliant regimens had significantly fewer COPD-related inpatient and emergency department visits and therefore had significantly lower COPD-related medical costs in both the GOLD A/B and C/D cohorts. Similar results were observed for individual GOLD cohorts B, C, and D. These savings were offset by increased pharmacy expenditures. Being on GOLD guideline-compliant regimens significantly reduced the risk of exacerbation by 8% (hazard ratio [HR] = 0.92; P < 0.0001) in the GOLD A/B cohort and by 12% (HR = 0.88; P = 0.0005) in the GOLD C/D cohort, and was also associated with a significantly reduced exacerbation rate in the GOLD A/B (rate ratio [RR] = 0.93; P < 0.0001) and GOLD C/D (RR = 0.93; P = 0.0129) groups. CONCLUSIONS: This study suggests a continuing trend of high prevalence of suboptimal prescriber compliance to GOLD treatment recommendations. Treatment regimens compliant with GOLD recommendations were associated with improvement in exacerbations, reduced COPD-related HRU, and COPD-related medical cost offsets. DISCLOSURES: This study was funded by Boehringer Ingelheim Pharmaceuticals, Inc. (BIPI). BIPI was given the opportunity to review the manuscript for medical and scientific accuracy as well as intellectual property considerations. Palli and Shaikh are employees of BIPI. Willey is an employee of HealthCore, which was contracted by BIPI to conduct this study. Zhou was an employee of HealthCore at the time of study execution. Data were presented in part during an AMCP webinar (recording not made public) held in lieu of the Spring 2020 AMCP conference, which was canceled due to the COVID-19 pandemic.

Can Technology-Based Physical Activity Programs for Chronic Obstructive Pulmonary Disease Be Cost-Effective?

Objective: To evaluate the cost-effectiveness of a technology-based physical activity (PA) intervention for chronic obstructive pulmonary disease (COPD). Design: A secondary data analysis was performed from a randomized controlled trial in COPD of an activity monitor alone or an activity monitor plus a web-based PA intervention. Models estimated cost per quality-adjusted life year (QALY) and incremental cost-effectiveness ratios (ICERs) compared with usual care. Results: The estimated ICER for both groups was below the willingness-to-pay threshold of $50,000/QALY (activity monitor alone = $10,437/QALY; website plus activity monitor intervention = $13,065/QALY). A probabilistic simulation estimated 76% of the activity monitor-alone group and 78% of the intervention group simulations to be cost-effective. Conclusion(s): Both the activity monitor-alone group and the activity monitor plus website group were cost-effective at the base case by using conventional willingness-to-pay thresholds. Further research would benefit from a more direct estimate of health utilities and downstream health care costs. Clinical Trials.gov NCT01102777.

Quality Assessment of an Integrated Care Pathway Using Telemonitoring in Patients with Chronic Heart Failure and Chronic Obstructive Pulmonary Disease: Protocol for a Quasi-Experimental Study

Background

Chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD) often coexist and are associated with a high morbidity and reduced quality of life (QoL). Although these diseases share similarities in symptoms and clinical course, and exacerbations of both diseases often overlap, care pathways for both conditions are usually not integrated. This results in frequent outpatient consultations and suboptimal treatment during exacerbations, leading to frequent hospital admissions. Therefore, we propose an integrated care pathway for both diseases, using telemonitoring to detect deterioration at an early stage and a single case manager for both diseases.

Objective

This study aims to investigate whether an integrated care pathway using telemonitoring in patients with combined CHF and COPD results in a higher general health-related QoL (HRQoL) as compared with the traditional care pathways. Secondary end points include disease-specific HRQoL, level of self-management, patient satisfaction, compliance to the program, and cost-effectiveness.

Methods

This is a monocenter, prospective study using a quasi-experimental interrupted time series design. Thirty patients with combined CHF and COPD are included. The study period of 2.5 years per patient is divided into a preintervention phase (6 months) and a postintervention phase (2 years) in which end points are assessed. The intervention consists of an on-demand treatment strategy based on monitoring symptoms related to CHF/COPD and vital parameters (weight, blood pressure, heart rate, oxygen saturation, temperature), which are uploaded on a digital platform. The monitoring frequency and the limit values of the measurements to detect abnormalities are determined individually. Monitoring is performed by a case manager, who has the opportunity for a daily multidisciplinary meeting with both the cardiologist and the pulmonologist. Routine appointments at the outpatient clinic are cancelled and replaced by telemonitoring-guided treatment.

Results

Following ethical approval of the study protocol, the first patient was included in May 2018. Inclusion is expected to be complete in May 2021.

Conclusions

This study is the first to evaluate the effects of a novel integrated care pathway using telemonitoring for patients with combined CHF and COPD. Unique to this study is the concept of remote on-demand disease management by a single case manager for both diseases, combined with multidisciplinary meetings. Moreover, modern telemonitoring technology is used instead of, rather than as an addition to, regular care.

Trial Registration

Netherlands Trial Register NL6741; https://www.trialregister.nl/trial/6741

International Registered Report Identifier (IRRID)

DERR1-10.2196/20571

The Identification and Cost of Acute Chronic Obstructive Pulmonary Disease Exacerbations in a United States Population Healthcare Claims Database

Almost half of chronic obstructive pulmonary disease (COPD) exacerbations are estimated to be inaccurately reported by patients, inconsistently recorded in medical records, or not measured due to coding errors inherent to administrative claims. This retrospective observational study aimed to develop an algorithm capable of detecting acute COPD exacerbations (AECOPD) in healthcare claims and estimate costs associated with AECOPD over a 12-month period. Commercial and Medicare Advantage healthcare plan members (≥40 years old) with evidence of COPD were identified from US healthcare-claims database. To refine the algorithm detecting AECOPD in claims data, sensitivity and positive-predictive value calculations were performed to compare AECOPD identification in healthcare claims versus medical charts. Analyses were also performed to examine total exacerbation-related costs for events identified with the new claims algorithm plus events missed. The final algorithm had a sensitivity of 84.9%, with a positive-predictive value of 67.5%. Medical records were abstracted for 402 patients. In the overall sample of healthcare claims (n = 243,998), the algorithm detected ≥1 AECOPD event in 61.3% of patients. The mean cost per patient during an AECOPD episode, identified by the final algorithm, was USD 6,760 (n = 301), with an incremental average cost of USD 607 (n = 122) to 'unobserved' episodes (not reported in claims data) among the chart sample. After multivariate modeling, predicted yearly exacerbation costs translated to USD 1.12 billion per 100,000 patients (USD 12,000 per patient), with 35.76 million associated with unobserved exacerbations. While the final algorithm warrants further validation and study, these findings highlight unobserved AECOPD and their economic burden.

Standardized Extract of Atractylodis Rhizoma Alba and Fructus Schisandrae Ameliorates Coughing and Increases Expectoration of Phlegm

Cough and phlegm frequently occur in respiratory diseases like upper respiratory tract infections, acute bronchitis, and chronic obstructive pulmonary diseases. To relieve these symptoms and diseases, various ingredients are being used despite the debates on their clinical efficacy. We aimed to investigate the effects of the extract CKD-497, composed of Atractylodis Rhizoma Alba and Fructus Schisandrae, in relieving cough and facilitating expectoration of phlegm. CKD-497 was found to inhibit inflammatory mediators such as interleukin-8 (IL-8) and tumor necrosis factor α (TNF-α) in lipopolysaccharide (LPS)-treated mouse macrophages and transient receptor potential cation channel 1 (TRPV-1)-overexpressed human bronchial epithelial cells stimulated by capsaicin. CKD-497 decreased the viscosity of the mucin solution. During in vivo experiments, CKD-497 reduced coughing numbers and increased expectoration of phlegm via mucociliary clearance enhancement. Collectively, these data suggest that CKD-497 possesses potential for cough and phlegm expectoration treatment.

[Assessment of the respiratory muscles strength at patients with chronic obstructive pulmonary disease with various forms of comorbidity]

The respiratory muscles (RM) strength is the main indicator of their functional state. However, RM strength is not used as criteria for chronic obstructive pulmonary disease (COPD) stratification.

AIM

To evaluate the RM power of COPD patients with various variants of comorbidity and to determine the role of comorbidity in the development of respiratory muscle dysfunction.

MATERIALS AND METHODS

RM strength of 64 men with exacerbation of COPD was studied. The severity of comorbidity was assessed by the Charlson index. Depending on the prevalence of comorbidity, patients were divided into 3 groups: cardiovascular, cerebrovascular and metabolic. Maximum inspiratory (MIP) and expiratory (MEP) pressures in the oral cavity, maximum rate of pressure development (MRPD), sniff nasal inspiratory pressure (SNIP), MEP/MIP and SNIP/MIP indexes were determined with MicroRPM device (UK). Measured values of MIP, MEP and SNIP were compared with the proper ones. The most noticeable decrease of RM strength was defined in the group of patients with severe comorbidity.

RESULTS

In case of a mild comorbidity MEP and SNIP values were 68 and 78% of the predicted values and MIP value corresponded to the personified standard. RM strength of patients with COPD depended on the clinical variant of comorbidity. Thus, in the group of patients with cardiovascular variant of comorbidity auxiliary inspiratory muscles strength decreased. In the group of patients with cerebrovascular variant of comorbidity the expiratory muscles dysfunction predominated. In the group of patients with metabolic variant of comorbidity diaphragm dysfunction predominated.

CONCLUSION

The pathogenetic significance of various factors of COPD comorbidity in the development of RM dysfunction was confirmed by the results of the correlation analysis.

The economic burden of chronic obstructive pulmonary disease (COPD) in Europe: results from a systematic review of the literature

OBJECTIVES

To find the economic burden of COPD and to identify the key cost drivers in the management of COPD patients across different European countries.

BACKGROUND

COPD is a major cause of mortality and morbidity and is associated with considerable economic burden on the individual and society. It limits the daily activities and working ability of the patients.

METHODOLOGY

We conducted a systematic search of PUBMED, SCIENCE DIRECT, Cochrane CENTRAL, SCOPUS, Google Scholar and SAGE Premier Databases to find scientific research articles evaluating the cost of COPD management from patient and societal perspective.

RESULTS

Estimated per patient per year direct cost in Norway, Denmark, Germany, Italy, Sweden, Greece, Belgium, and Serbia was €10,701, €9580, €7847, €7448, €7045, €2896, €1963, and €2047, respectively. Annual per patient cost of work productivity loss was highest in Germany as €5735 and lowest in Greece as €998. It was estimated as €4824, €2033 and €1298 in Bulgaria, Denmark and Sweden, respectively. Several factors found associated with increasing cost of COPD management that include but not limited to late diagnosis, severity of disease, frequency of exacerbation, hospital readmissions, non-adherence to the therapy and exposure to COPD risk factors.

CONCLUSION

Minimizing the COPD exacerbations and controlling the worsening of symptoms may potentially reduce the cost of COPD management at any stage.

Prevalence of disability among adults with chronic obstructive pulmonary disease, Behavioral Risk Factor Surveillance System 2016-2017

BACKGROUND

The prevalence of disabilities is rising steadily, reflecting an aging population and an increasing burden of chronic conditions affecting quality of life. There are scant national data on the prevalence of disability among individuals with chronic obstructive pulmonary disease (COPD). The main objective was to estimate the prevalence of common disabilities among US-based individuals diagnosed with COPD.

METHODS

Data from the BRFSS, a national telephone survey examining health-related behaviors in 2016-2017 were analyzed. The study population consisted of individuals with self-reported COPD (N = 38352 in 2016 and N = 35423 in 2017). The prevalence of disabilities in hearing, vision, cognition, mobility, and independent living were obtained and adjusted with sampling weights. Healthcare access measures were described by type of disability.

RESULTS

Mobility disability had the highest prevalence of 45.9 (44.8-47.0) % in 2016 and 48.4 (47.3-49.5) % in 2017 among respondents with COPD. The prevalence of disabilities was highest among those 45-64 years old, except for hearing and cognition. Hearing disabilities were most prevalent among males with COPD while cognitive and mobility disabilities were most prevalent among females with COPD. While differences in the prevalence of disabilities were observed, access to health care was similar by disability type and age group among respondents.

CONCLUSION

Contrary to expectation, the highest prevalence of disabilities was found not to be among those 65 years old and above. Further research is needed to explain this age-specific shift in the burden of disability, as long-term care planning and prevention support systems should be informed by the demographical patterns of disabilities among individuals with COPD.

Economic Burden of Chronic Obstructive Pulmonary Disease (COPD): A Systematic Literature Review

Background and Objectives

Chronic obstructive pulmonary disease (COPD) affects over 250 million people globally, carrying a notable economic burden. This systematic literature review aimed to highlight the economic burden associated with moderate-to-very severe COPD and to investigate key drivers of healthcare resource utilization (HRU), direct costs and indirect costs for this patient population.

Materials and Methods

Relevant publications published between January 1, 2006 and November 14, 2016 were captured from the Embase, MEDLINE and MEDLINE In-Process databases. Supplemental searches from relevant 2015-2016 conferences were also performed. Titles and abstracts were reviewed by two independent researchers against pre-defined inclusion and exclusion criteria. Studies were grouped by the type of economic outcome presented (HRU or costs). Where possible, data were also grouped according to COPD severity and/or patient exacerbation history.

Results

In total, 73 primary publications were included in this review: 66 reported HRU, 22 reported direct costs and one reported indirect costs. Most of the studies (94%) reported on data from either Europe or North America. Trends were noted across multiple studies for higher direct costs (including mean costs per patient per year and mean costs per exacerbation) being associated with increasingly severe COPD and/or a history of more frequent or severe exacerbations. Similar trends were noted according to COPD severity and/or exacerbation history for rate of hospitalization and primary care visits. Multivariate analyses were reported by 29 studies and demonstrated the statistical significance of these associations. Several other drivers of increased costs and HRU were highlighted for patients with moderate-to-very severe COPD, including comorbidities, and treatment history.

Conclusion

Moderate-to-very severe COPD represents a considerable economic burden for healthcare providers despite the availability of efficacious treatments and comprehensive guidelines on their use. Further research is warranted to ensure cost-efficient COPD management, to improve treatments and ease budgetary pressures.

Combined Antioxidant, Anti-inflammaging and Mesenchymal Stem Cell Treatment: A Possible Therapeutic Direction in Elderly Patients with Chronic Obstructive Pulmonary Disease

Chronic Obstructive Pulmonary Disease (COPD) is a worldwide health problem associated with high morbidity and mortality, especially in elderly patients. Aging functions include mitochondrial dysfunction, cell-to-cell information exchange, protein homeostasis and extracellular matrix dysregulation, which are closely related to chronic inflammatory response and oxidation-antioxidant imbalance in the pathogenesis of COPD. COPD displays distinct inflammaging features, including increased cellular senescence and oxidative stress, stem cell exhaustion, alterations in the extracellular matrix, reduced levels of endogenous anti-inflammaging molecules, and reduced autophagy. Given that COPD and inflammaging share similar general features, it is very important to identify the specific mechanisms of inflammaging, which involve oxidative stress, inflammation and lung mesenchymal stem cell function in the development of COPD, especially in elderly COPD patients. In this review, we highlight the studies relevant to COPD progression, and focus on mechanisms associated with inflammaging.

The Burden of Cough and Phlegm in People With COPD: A COPD Patient-Powered Research Network Study

Rationale

Cough and phlegm are common symptoms of chronic obstructive pulmonary disease (COPD) and may significantly affect quality of life. This study assessed the burden of cough and phlegm on clinical outcomes and quality of life among people with a self-reported physician diagnosis of COPD.

Methods

Patient-reported data from the COPD Foundation's Patient-Powered Research Network (COPD PPRN) were utilized. Cough and phlegm severity and frequency were assessed by responses to questions on the COPD Assessment Test (CAT) and categorized into none/low, moderate and severe. Quality of life domains were evaluated using the Patient-Reported Outcome Measurement Information System (PROMIS-29). Associations between cough and phlegm levels and PROMIS-29 domains were examined using multivariate analysis of variance (MANOVA).

Results

The 5286 participants were average age 64.4 years (SD=11.4), 87.9% white, 60.4% female, 51.2% married, and 42.2% with caregivers. Approximately three-fourths of the participants had moderate or severe cough or phlegm levels. Respondents with moderate and high cough or phlegm had significantly worse dyspnea (p<0.0001), more exacerbations in the previous one year (p<0.0001), worse physical and social functioning, and more symptoms of anxiety and depression on PROMIS-29 compared to those with no/low cough and phlegm.

Conclusions

In this group of people with COPD, higher levels of cough and phlegm are associated with worse clinical and quality of life outcomes.

Acceptance of Illness Associates with Better Quality of Life in Patients with Nonmalignant Pulmonary Diseases

Chronic nonmalignant pulmonary diseases impose a heavy burden on patients, generate health-care costs, and contribute to poor health-related quality of life. It has been found that a wide range of factors negatively affects quality of life, but the role of acceptance of illness needs to be further investigated. The aim of the study was to evaluate the relationship between acceptance of illness and quality of life in patients with chronic nonmalignant pulmonary diseases. The study encompassed 200 patients of the mean age 58 ± 16 years who were mainly diagnosed with asthma (n = 72; 36%), COPD (n = 52; 26%), and obstructive sleep apnea (n = 38; 19%). The patients answered the Acceptance of Illness Scale (AIS) and the St. George's Respiratory Questionnaire (SGRQ). Sociodemographical and clinical data were collected. The level of acceptance of illness significantly associated with each of the SGRQ domains. The greater the acceptance of illness, the lowest was the SGRQ score. The mean total score of SGRQ was 44.6 ± 24.9 and that of AIS was 26.1 ± 8.2. Higher AIS scores significantly associated with lower SGRQ scores, i.e., with better quality of life (p < 0.001 for each domain). We conclude that in patients with chronic nonmalignant pulmonary diseases, acceptance of illness plays an important role and is closely related to the general level of quality of life. Interventions aimed at improving acceptance of illness may be considered to improve quality of life.

Living with chronic obstructive pulmonary disease: A story conditioned by the symptoms

OBJECTIVE

To determine the meaning of the experience of people with chronic obstructive pulmonary disease.

METHOD

A qualitative approach study rooted in hermeneutic phenomenology. In-depth interviews were conducted with 10 people with critical and severe chronic obstructive pulmonary disease.

RESULTS

The findings obtained are described in three emerging topics and their consequent subtopics, which describe the process of the disease focusing on five subtopics related to awareness of the disease, the choking characteristic of the disease and tiredness as daily unpleasant symptoms, as well as choking as a death threat, rejection of oxygen dependency and coping systems to control the disease. In the second topic, family support with two subtopics are described: the loss of the patient's role, the burden of care; and the third topic concerns the support of health system on two subtopics: medical care and nursing care.

CONCLUSION

The symptoms and functional changes in general, denote a different meaning not only in everyday life, but also in times of exacerbation of the condition. Likewise, changes in lifestyle due to the loss of roles and health care processes are revealed, as experiences that do not allow effective coping and adaptation.

Prior cigarette smoke exposure does not affect acute post-stroke outcomes in mice

Chronic obstructive pulmonary disease (COPD) is currently the third leading cause of death globally and is characterized by airflow limitation that is progressive and not fully reversible. Cigarette smoking is the major cause of COPD. Fifty percent of deaths in the COPD population are due to a cardiovascular event and it is now recognised that COPD is a risk factor for stroke. Whether COPD increases stroke severity has not been explored. The aim of this study was to investigate whether functional and histological endpoints of stroke outcomes in mice after transient middle cerebral artery occlusion (tMCAo) were more severe in mice exposed to cigarette smoke (CS). 7-week-old male C57BL/6 mice were exposed to room air or CS generated from 9 cigarettes/day, 5 days/week for 2, 8 and 12 weeks. Following air or CS exposure, mice underwent tMCAO surgery with an ischaemic period of 30-40 min or sham surgery. Mice were euthanised 24 h following the induction of ischaemia and bronchoalveolar lavage fluid (BALF), lungs and brains collected. Mice exposed to CS for 2 weeks and subjected to a stroke had similar BALF macrophages to air-exposed and stroke mice. However, CS plus stroke mice had significantly more BALF total cells, neutrophils and lymphocytes than air plus stroke mice. Mice exposed to CS for 8 and 12 weeks had significantly greater BALF total cells, macrophages, neutrophils and lymphocytes than air-exposed mice, but stroke did not affect CS-induced BALF cellularity. Prior CS exposure did not worsen stroke-induced neurological deficit scores, reduced foregrip strength, infarct and oedema volumes. Collectively, we found that although CS exposure caused significant BALF inflammation, it did not worsen acute post-stroke outcomes in mice. This data suggests that while patients with COPD are at increased risk of stroke, it may not translate to COPD patients having more severe stroke outcomes.

The Economic Effect of Early Management in Patients with Early Chronic Obstructive Pulmonary Disease: Results from a Population-Based Nationwide Survey

PURPOSE

The economic effect of regular follow-up and early management in patients with early chronic obstructive pulmonary disease (COPD) has not yet been clarified. Therefore, this study aimed to estimate the economic effect of regular follow-up and early management in these patients.

METHODS

Patients with early COPD were identified from the Korea National Health and Nutrition Examination Survey. We analyzed medical utilization and cost for 2 years without any missing data by using the Korean National Health Insurance data. Patients with routine healthcare maintenance were defined as, after diagnosis, those with regular visits to the hospital and receiving early management of COPD.

RESULTS

Among 1204 patients with early COPD, the patients who were classified as the group with routine healthcare maintenance (69/146; 47.3%) and the group with intermittent healthcare user (79/1058; 7.5%) visited to hospital for the next 2 years. The patients with routine healthcare maintenance had lower cost of inpatient service and frequencies of emergency room (ER) visit and intensive care unit (ICU) admission than intermittent healthcare users (cost of inpatient service, $4595 vs. $4953 per person; ER visit, 7.2 vs. 11.5; ICU admission, 4.3 vs. 7.7). Even in patients with COPD and FEV₁ ≥ 80, early intervention through follow-up reduced the cost of inpatient service because these patients could have had less severe acute exacerbations than intermittent healthcare users.

CONCLUSION

Patients with early COPD, even those with FEV₁ ≥ 80, need regular follow-up for early management and disease control as well as for reducing the socioeconomic burden of the disease.

Predictive factors for exacerbation and re-exacerbation in chronic obstructive pulmonary disease: an extension of the Cox model to analyze data from the Swiss COPD cohort

Background

The Swiss COPD cohort was established in 2006 to collect data in a primary care setting. The objective of this study was to evaluate possible predictive factors for exacerbation and re-exacerbation.

Methods

In order to predict exacerbation until the next visit based on the knowledge of exacerbation since the last visit, a multistate model described by Therneau and Grambsch was performed.

Results

Data of 1,247 patients (60.4% males, 46.6% current smokers) were analyzed, 268 (21.5%) did not fulfill spirometric diagnostic criteria for COPD. Data of 748 patients (63% males, 44.1% current smokers) were available for model analysis. In order to predict exacerbation an extended Cox Model was performed. Mean FEV₁/FVC-ratio was 53.1% (±11.5), with a majority of patients in COPD GOLD classes 2 or 3. Hospitalization for any reason (HR1.7; P = 0.04) and pronounced dyspnea (HR for mMRC grade four 3.0; P < 0.001) at most recent visit as well as prescription of short-acting bronchodilators (HR1.7; P < 0.001), inhaled (HR1.2; P = 0.005) or systemic corticosteroids (HR1.8; P = 0.015) were significantly associated with exacerbation when having had no exacerbation at most recent visit. Higher FEV₁/FVC (HR0.9; P = 0.008) and higher FEV₁ values (HR0.9; P = 0.001) were protective. When already having had an exacerbation at the most recent visit, pronounced dyspnea (HR for mMRC grade 4 1.9; P = 0.026) and cerebrovascular insult (HR2.1; P = 0.003) were significantly associated with re-exacerbation. Physical activity (HR0.6; P = 0.031) and treatment with long-acting anticholinergics (HR0.7; P = 0.044) seemed to play a significant protective role. In a best subset model for exacerbation, higher FEV₁ significantly reduced and occurrence of sputum increased the probability of exacerbation. In the same model for re-exacerbation, coronary heart disease increased and hospitalization at most recent visit seemed to reduce the risk for re-exacerbation.

Conclusion

Our data confirmed well-established risk factors for exacerbations whilst analyzing their predictive association with exacerbation and re-exacerbation. This study confirmed the importance of spirometry in primary care, not only for diagnosis but also as a risk evaluation for possible future exacerbations.

Trial registration

Our study got approval by local ethical committee in 2006 (EK Nr. 170/06) and was registered retrospectively on ClinicalTrials.gov (NCT02065921, 19^th of February 2014).

An attempt at modeling COPD epidemiological trends in France

Background

Anticipating the future burden of chronic obstructive pulmonary disease (COPD) is required to develop adequate public health policies.

Methods

A dynamic population model was built to estimate COPD prevalence by 2025 using data collected during the most recent large general population study on COPD prevalence in France (2005) as baseline values. Sensitivity analyses were performed to test the effect of variations in key input variables.

Results

The model predicted a steady increase in crude COPD prevalence among subjects aged≥45 years from 2005 (prevalence estimate: 84.51‰) to 2025 (projected prevalence: 95.76‰, + 0.56‰/yr). There was a 4-fold increase in the prevalence of GOLD grade 3–4 cases, a 23% relative increase in women and a 21% relative increase in subjects ≥75 years. In sensitivity analyses, these temporal trends were robust. Factors associated with > 5% relative variations in projected 2025 prevalence estimates were baseline prevalence and severity distribution, incidence in women and severity of incident cases, transition rates between severity grades, and mortality.

Conclusions

Projections of future COPD epidemiology consistently predict an increase in the prevalence of moderate-to-very severe COPD, especially due to increases among women and subjects aged ≥75 years. Developing robust prediction models requires collecting reliable data on current COPD epidemiology.

Electronic supplementary material

The online version of this article (10.1186/s12931-018-0827-7) contains supplementary material, which is available to authorized users.

Respiratory problems in low-resource settings

PURPOSE OF REVIEW

Chronic breathlessness is common in patients with advanced illness who require palliative care. Achieving good symptom control can be challenging. More people with advanced illness live in low and middle income than in high-income countries, but they are much less likely to receive palliative care. Most of the emerging evidence for the palliative management of chronic breathlessness is from high-income countries. This review explores the context of chronic breathlessness in low-income settings, how evidence for control of chronic breathlessness might relate to these settings and where further work should be focused.

RECENT FINDINGS

Systems for control of noncommunicable diseases (NCDs) in these low-income contexts are poorly developed and health services are often overwhelmed with high levels both of NCD and communicable disease. Multidisciplinary and holistic approaches to disease management are often lacking in these settings. Developing an integrated primary care approach to NCD management is increasingly recognized as a key strategy and this should include palliative care. Most evidence-based approaches to the control of chronic breathlessness could be adapted for use in these contexts SUMMARY: Hand held fans, breathing techniques, graded exercise and use of low-dose morphine can all be used in low-income settings particularly in the context of holistic care. Research is needed into the most effective ways of implementing such interventions and palliative care needs to be promoted as a fundamental aspect of NCD management.

The COPD Assessment Test (CAT) can screen for fatigue among patients with COPD

BACKGROUND

Fatigue is one of the most common symptoms among subjects with chronic obstructive pulmonary disease (COPD), but is rarely identified in clinical practice. The aim of this study was to evaluate the association between fatigue and health-related quality of life (HRQoL) assessed with clinically useful instruments, both among subjects with and without COPD. Further, to investigate the association between fatigue and the COPD Assessment Test (CAT)-energy question.

METHODS

Data were collected in 2014 within the population-based OLIN COPD study. Subjects with ( n = 367) and without ( n = 428) COPD participated in clinical examinations including spirometry and completed questionnaires about fatigue (FACIT-Fatigue, clinically relevant fatigue ⩽43), and HRQoL (EQ-5D-VAS, lower score = worse health; CAT, lower score = fewer symptoms/better health).

RESULTS

Subjects with clinically relevant fatigue had worse HRQoL measured with EQ-5D-VAS, regardless of having COPD or not. Decreasing EQ-5D-VAS scores, any respiratory symptoms and anxiety/depression were associated with clinically relevant fatigue also when adjusted for confounders. Among subjects with COPD, clinically relevant fatigue was associated with increasing total CAT score, and CAT score ⩾10. The proportion of subjects with clinically relevant fatigue increased significantly, with a higher score on the CAT-energy question, and nearly 50% of those with a score of 2, and 70% of those with a score of ⩾3, had clinically relevant fatigue.

CONCLUSIONS

Fatigue was associated with respiratory symptoms, anxiety/depression and worse HRQoL when using the clinically useful instruments EQ-5D-VAS and CAT. The CAT-energy question can be used to screen for fatigue in clinical practice, using a cut-off of ⩾2.

Clinical and economic burden of dyspnea and other COPD symptoms in a managed care setting

PURPOSE

The degree to which symptoms such as dyspnea affect patients with COPD is individualized. To address the gap between clinical symptom measures and self-perceived disease burden, we investigated the symptom status of adult patients with COPD and followed with an administrative claims analysis of health care resource utilization and costs.

METHODS

This was a hybrid US observational study consisting of a cross-sectional patient survey followed by a retrospective analysis of administrative claims data. The primary COPD symptom measures were the modified Medical Research Council (mMRC) Dyspnea scale and the COPD Assessment Test (CAT).

RESULTS

A total of 673 patients completed the survey. Of these, 65% reported mMRC grades 0-1 (low symptomatology) and 35% reported mMRC grades 2-4 (high symptomatology); 25% reported CAT score <10 (low symptomatology) and 75% reported CAT score ≥10 (high symptomatology). More patients with high symptomatology (by either measure) had at least one COPD-related inpatient hospitalization, emergency room visit, physician office visit, or other outpatient services, and filled at least one COPD-related prescription medication vs patients with low symptomatology. COPD-related costs were higher for patients with high symptomatology than patients with low symptomatology. In a multivariate analysis, COPD-related costs were also higher in patients reporting severe symptoms.

CONCLUSION

Patients with high COPD symptomatology utilized more health care resources and had higher COPD-related health care costs during the 6-month post-survey period than patients with low symptomatology.

COPD and stroke: are systemic inflammation and oxidative stress the missing links?

Chronic obstructive pulmonary disease (COPD) is characterized by progressive airflow limitation and loss of lung function, and is currently the third largest cause of death in the world. It is now well established that cardiovascular-related comorbidities such as stroke contribute to morbidity and mortality in COPD. The mechanisms linking COPD and stroke remain to be fully defined but are likely to be interconnected. The association between COPD and stroke may be largely dependent on shared risk factors such as aging and smoking, or the association of COPD with traditional stroke risk factors. In addition, we propose that COPD-related systemic inflammation and oxidative stress may play important roles by promoting cerebral vascular dysfunction and platelet hyperactivity. In this review, we briefly discuss the pathogenesis of COPD, acute exacerbations of COPD (AECOPD) and cardiovascular comorbidities associated with COPD, in particular stroke. We also highlight and discuss the potential mechanisms underpinning the link between COPD and stroke, with a particular focus on the roles of systemic inflammation and oxidative stress.

A cross-sectional assessment of the burden of COPD symptoms in the US and Europe using the National Health and Wellness Survey

INTRODUCTION

Past research has suggested significant relationships between symptoms and health outcomes among patients with COPD. However, these studies have generally focused on a broad COPD sample and may have included those not receiving proper treatment. As a result, the aim of this study was to document the burden of COPD symptoms among those who are currently treated with the standard-of-care (SOC) medications in both the US and Western Europe.

METHODS

Data from the 2013 US (N=75,000) and 2011 (N=57,512)/2013 (N=62,000) European (France, Germany, Italy, Spain, and UK; 5EU) National Health and Wellness Survey (NHWS) were used. The NHWS is a health survey administered to a demographically representative sample of the adult population in each country. A total of 1,666 and 2,006 patients with self-reported physician diagnosis of COPD in the 5EU and US, respectively, were being treated with the appropriate SOC (based on self-reported medication use) and were included in the analyses. Symptoms (eg, dyspnea, coughing, wheezing) were reported descriptively and summed to create a symptom score (with higher score indicating more frequent symptoms). The relationships between the symptom score and patient outcomes (eg, health status using the Short Form-36 version 2 [SF-36v2], work productivity and activity impairment [WPAI], and self-reported health care resource use) were explored using regression modeling.

RESULTS

Nearly all patients (99.7% and 99.8% in the 5EU and US, respectively) reported experiencing symptoms and >80% reported experiencing at least one symptom "often". Increasing symptom scores were associated with poorer health status (unstandardized beta [b] =-0.87 and -0.78 for mental component summary and physical component summary, respectively, in the US and b =-0.67 and -0.79 in the 5EU, respectively; all P<0.05). Increasing symptom scores were also associated with greater work impairment (b =0.09 and 0.06 for the US and 5EU, respectively), activity impairment (b =0.05 and 0.06, respectively), and health care resource utilization (eg, hospitalizations: b =0.05 and 0.06, respectively) (all P<0.05). Approximately 70% of patients reported some level of non-adherence. Greater non-adherence was significantly associated with more frequent symptoms, poorer health status, and greater work impairment and health care resource use (all P<0.05).

CONCLUSION

Patients with COPD who are using the appropriate SOC still experience symptoms, which have a significant effect on both humanistic and economic outcomes.

A Systematic Review of Health Economics Simulation Models of Chronic Obstructive Pulmonary Disease

BACKGROUND

Many decision-analytic models with varying structures have been developed to inform resource allocation in chronic obstructive pulmonary disease (COPD).

OBJECTIVES

To review COPD models for their adherence to the best practice modeling recommendations and their assumptions regarding important aspects of the natural history of COPD.

METHODS

A systematic search of English articles reporting on the development or application of a decision-analytic model in COPD was performed in MEDLINE, Embase, and citations within reviewed articles. Studies were summarized and evaluated on the basis of their adherence to the Consolidated Health Economic Evaluation Reporting Standards. They were also evaluated for the underlying assumptions about disease progression, heterogeneity, comorbidity, and treatment effects.

RESULTS

Forty-nine models of COPD were included. Decision trees and Markov models were the most popular techniques (43 studies). Quality of reporting and adherence to the guidelines were generally high, especially in more recent publications. Disease progression was modeled through clinical staging in most studies. Although most studies (n = 43) had incorporated some aspects of COPD heterogeneity, only 8 reported the results across subgroups. Only 2 evaluations explicitly considered the impact of comorbidities. Treatment effect had been mostly modeled (20) as both reduction in exacerbation rate and improvement in lung function.

CONCLUSIONS

Many COPD models have been developed, generally with similar structural elements. COPD is highly heterogeneous, and comorbid conditions play an important role in its burden. These important aspects, however, have not been adequately addressed in most of the published models.

Do Model-Based Studies in Chronic Obstructive Pulmonary Disease Measure Correct Values of Utility? A Meta-Analysis

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a progressive chronic disease that has considerable impact on utility-based health-related quality of life. Utility is a key input of many decision analytic models used for economic evaluations.

OBJECTIVE

To systematically review COPD-related utilities and to compare these with alternative values used in decision models.

METHODS

The literature review comprised studies that generated utilities for COPD-related stages based on EuroQol five-dimensional questionnaire surveys of patients and of decision models of COPD progression that have been used for economic evaluations. The utility values used in modeling studies and those from the meta-analysis of actual patient-level studies were compared and differences quantified.

RESULTS

Twenty decision modeling studies that used utility value as an input parameter were found. Within the same span of publication period, 13 studies involving patient-level utility data were identified and included in the meta-analysis. The estimated mean utility values ranged from 0.806 (95% confidence interval [CI] 0.747-0.866) for stage I to 0.616 (95% CI 0.556-0.676) for stage IV. The utility scores for comparable stages in modeling studies were different (significant difference 0.045 [95% CI 0.041-0.052] for stage III). Modeling studies consistently used higher utility values than the average reported patient-level data.

CONCLUSIONS

COPD decision analytic models are based on a limited range of utility values that are systematically different from average values estimated using a meta-analysis. A more systematic approach in the application of utility measures in economic evaluation is required to appropriately reflect current literature.

Assessing health-related quality of life in COPD: comparing generic and disease-specific instruments with focus on comorbidities

Background

Chronic Obstructive Pulmonary Disease (COPD) influences different aspects of patient’s health-related quality of life (HRQL). While disease-specific HRQL instruments focus on symptoms and functional impairments, generic instruments cover a broader view on health. This study compares the generic EQ-5D-3 L and two disease-specific questionnaires (St.-George’s Respiratory Questionnaire (SGRQ-C), COPD Assessment Test (CAT)) in a comprehensive spectrum of COPD disease grades with particular attention on comorbidities and assesses the discriminative abilities of these instruments.

Methods

Using data from the baseline visit of the German COPD cohort COSYCONET, mean HRQL scores in different COPD grades were compared by linear regression models adjusting for age, sex, education, smoking status, BMI, and low vs. high number of comorbidities or a list of several self-reported comorbid conditions. Discriminative abilities of HRQL instruments to differentiate between COPD grades were assessed by standardized mean differences.

Results

In 2,291 subjects in COPD GOLD grades 1–4 EQ-5D-3 L utility, EQ-5D VAS, SGRQ, and CAT were found able to discriminate between COPD grades, with some limitations for the EQ-5D utility in mild disease. Both generic and disease-specific HRQL instruments reflected the burden of comorbid conditions. The SGRQ showed the best discrimination between COPD grades and was less influenced by comorbidities, while EQ-5D utility put a higher weight on comorbid conditions. For all instruments, psychiatric disorders and peripheral artery disease showed the strongest negative associations with HRQL.

Conclusion

All HRQL instruments considered reflect considerable impairment of HRQL in COPD patients, worsening with increasing COPD grade and number of comorbidities. Findings may support clinical assessment, choice of HRQL instrument in future studies, and parameterization of decision-analytic models.

Electronic supplementary material

The online version of this article (doi:10.1186/s12890-016-0238-9) contains supplementary material, which is available to authorized users.

Health Status of Patients With Chronic Obstructive Pulmonary Disease by Symptom Level

Background: Despite receiving treatment, patients with chronic obstructive pulmonary disease (COPD) often continue to experience symptoms that impact their health status. We determined the relationship between overall symptom burden and health status, and assessed the treatments patients were receiving. Methods: Data from 3 cross-sectional surveys of U.S. patients with COPD (2011-2013) were analyzed. Patients receiving inhaled COPD treatment for ≥3 months completed the COPD Assessment Test (CAT) symptom burden and respiratory health status measure, EuroQol 5-dimension (EQ-5D-3L) general health status questionnaire, and Jenkins Sleep Evaluation Questionnaire (JSEQ). CAT scores were used to identify high- (CAT ≥24) and low-symptom patients (CAT <24), who were matched using 1:1 propensity score matching with replacement. Match balance was assessed with standardized mean differences. EQ-5D-3L and JSEQ scores, and current treatment were compared between groups post-matching. Sensitivity was assessed with Rosenbaum bounds. Results: A total of 638 patients were included. Compared with low-symptom patients, high-symptom patients had worse health status and greater sleep disturbance by EQ-5D utility index (0.85 versus 0.71, respectively; p<0.0001) and JSEQ scores (3.73 versus 7.35, respectively; p<0.0001). High-symptom patients were prescribed single-maintenance bronchodilators ± inhaled corticosteroids (46.0%), triple therapy (40.5%), and short-acting therapy only (8.2%). Results were robust and insensitive to unobserved confounders. Conclusions: Increased COPD symptom burden is associated with worse general health status in patients receiving COPD treatment. High-symptom patients frequently received single inhaled medication. The results suggest that health care providers should monitor and tailor therapy, based on level of symptom burden to improve symptom control and health status.

Continuing to Confront COPD International Patient Survey: Economic Impact of COPD in 12 Countries

Background

The Continuing to Confront COPD International Patient Survey estimated the prevalence and burden of COPD across 12 countries. Using data from this survey we evaluated the economic impact of COPD.

Methods

This cross-sectional, population-based survey questioned 4,343 subjects aged 40 years and older, fulfilling a case definition of COPD based on self-reported physician diagnosis or symptomatology. Direct cost measures were based on exacerbations of COPD (treated and those requiring emergency department visits and/or hospitalisation), contacts with healthcare professionals, and COPD medications. Indirect costs were calculated from work loss values using the Work Productivity and Activity Impairment scale. Combined direct and indirect costs estimated the total societal costs per patient.

Results

The annual direct costs of COPD ranged from $504 (South Korea) to $9,981 (USA), with inpatient hospitalisations (5 countries) and home oxygen therapy (3 countries) being the key drivers of direct costs. The proportion of patients completely prevented from working due to their COPD ranged from 6% (Italy) to 52% (USA and UK) with 8 countries reporting this to be ≥20%. Total societal costs per patient varied widely from $1,721 (Russia) to $30,826 (USA) but a consistent pattern across countries showed greater costs among those with increased burden of COPD (symptoms, health status and more severe disease) and a greater number of comorbidities.

Conclusions

The economic burden of COPD is considerable across countries, and requires targeted resources to optimise COPD management encompassing the control of symptoms, prevention of exacerbations and effective treatment of comorbidities. Strategies to allow COPD patients to remain in work are important for addressing the substantial wider societal costs.

Age-Related Differences in Health-Related Quality of Life in COPD: An Analysis of the COPDGene and SPIROMICS Cohorts

OBJECTIVE

Younger persons with COPD report worse health-related quality of life (HRQL) than do older individuals. The factors explaining these differences remain unclear. The objective of this article was to explore factors associated with age-related differences in HRQL in COPD.

METHODS

Cross-sectional analysis of participants with COPD, any Global Initiative for Chronic Obstructive Lung Disease grade of airflow limitation, and ≥ 50 years old in two cohorts: the Genetic Epidemiology of COPD (COPDGene) study and the Subpopulations and Intermediate Outcome Measures in COPD Study (SPIROMICS). We compared St. George's Respiratory Questionnaire (SGRQ) scores by age group: middle-aged (age, 50-64) vs older (age, 65-80) adults. We used multivariate linear modeling to test associations of age with HRQL, adjusting for demographic and clinical characteristics and comorbidities.

RESULTS

Among 4,097 participants in the COPDGene study (2,170 middle-aged and 1,927 older adults) SGRQ total scores were higher (worse) among middle-aged (mean difference, -4.2 points; 95% CI, -5.7 to -2.6; P < .001) than older adults. Age had a statistically significant interaction with dyspnea (P < .001). Greater dyspnea severity (modified Medical Research Council ≥ 2, compared with 0-1) had a stronger association with SGRQ score among middle-aged (β, 24.6; 95% CI, 23.2-25.9) than older-adult (β, 21.0; 95% CI, 19.6-22.3) participants. In analyses using SGRQ as outcome in 1,522 participants in SPIROMICS (598 middle-aged and 924 older adults), we found similar associations, confirming that for the same severity of dyspnea there is a stronger association with HRQL among younger individuals.

CONCLUSIONS

Age-related differences in HRQL may be explained by a higher impact of dyspnea among younger subjects with COPD.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT00608764 and No.: NCT01969344; URL: www.clinicaltrials.gov.

COPD exacerbations by disease severity in England

OBJECTIVES

Exacerbations of chronic obstructive pulmonary disease (COPD) are associated with accelerated disease progression and are important drivers of health care resource utilization. The study aimed to quantify the rates of COPD exacerbations in England and assess health care resource utilization by severity categories according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2013.

METHODS

Data from the Clinical Practice Research Datalink linked to Hospital Episode Statistics were used to identify patients with a COPD diagnosis aged ≥40 years. Those with complete spirometric, modified Medical Research Council Dyspnea Scale information, and exacerbation history 12 months prior to January 1, 2011 (index date) were classified into GOLD severity groups. Study outcomes over follow-up (up to December 31, 2013) were exacerbation rates and resource utilization (general practitioner visits, hospital admissions).

RESULTS

From the 44,201 patients in the study cohort, 83.5% were classified into severity levels GOLD A: 33.8%, GOLD B: 21.0%, GOLD C: 18.1%, and GOLD D: 27.0%. Mean age at diagnosis was 66 years and 52.0% were male. Annual exacerbation rates per person-year increased with severity, from 0.83 (95% confidence interval [CI]: 0.81-0.85) for GOLD A to 2.51 (95% CI: 2.47-2.55) for GOLD D. General practitioner visit rates per person-year also increased with severity, from 4.82 (95% CI: 4.74-4.93) for GOLD A to 7.44 (95% CI: 7.31-7.61) for GOLD D. COPD-related hospitalization rates per person-year increased from less symptoms (GOLD A: 0.28, GOLD C: 0.39) to more symptoms (GOLD B: 0.52, GOLD D: 0.84).

CONCLUSION

Patients in the most severe category (GOLD D) experienced nearly three times the number of exacerbations and COPD-related hospitalizations as those in the least severe category (GOLD A), in addition to increased general practitioner visits. Better patient management to stabilize the disease progression could allow for an improvement in exacerbation frequency and a reduction in health care resource utilization.

Systematic review of models used in economic analyses in moderate-to-severe asthma and COPD

BACKGROUND

Respiratory diseases exert a substantial burden on society, with newer drugs increasingly adding to the burden. Economic models are often used, but seldom reviewed.

PURPOSE

To summarize economic models used in economic analyses of drugs treating moderate-to-severe/very severe asthma or chronic obstructive pulmonary disease (COPD).

METHODS

This study searched Medline and Embase from inception to the end of February 2015 for cost-effectiveness/utility analyses that examined at least one drug against placebo, another drug, or other standard therapy in asthma or COPD. Two reviewers independently searched and extracted data with differences adjudicated via consensus discussion. Data extracted included model used and its qualities, validation methods, treatments compared, disease severity, analytic perspective, time horizon, data collection (pro- or retrospective), input rates and sources, costs and sources, planned sensitivity analyses, criteria for cost-effectiveness, reported outcomes, and sponsor.

RESULTS

This study analyzed 53 articles; 14 (25%) on asthma and 39 (75%) COPD. Markov models were commonly used for both asthma and COPD-related economic evaluations. Relatively few studies validated their model. For asthma-related studies, 10 examined inhaled corticosteroids and nine studied omalizumab. Placebo or standard therapy was the comparison in 11 studies and active drugs in the remainder.

CONCLUSIONS

Few studies include validation of their models. Furthermore, controversy concerning some results was uncovered in this study, which needs to be avoided in the future.

Predictors of outcome in patients admitted with acute exacerbation of chronic obstructive pulmonary disease in a rural Tertiary Care Center

Background:

Chronic obstructive pulmonary disease (COPD) is associated with a high degree of mortality and morbidity around the world with the burden of the disease being more in the developing countries. In the Indian context data is limited. This study was carried out to determine the predictors of outcome in patients admitted with acute exacerbation of COPD in a rural Tertiary Care Center in the state of Kerala.

Materials and Methods:

This was a prospective cohort study. Patients admitted with acute exacerbation of COPD in the Intensive Care Unit between August 2013 and July 2014 was included in the study. Sociodemographic data, clinical variables, and investigations were collected. Mortality with respect to relevant risk factors was compared using Kaplan–Meier method and Cox proportional hazard model.

Results:

Seventy patients were enrolled in the study of whom 58 (82.9%) were above the age of 60 years. Majority of the patients (87.1%) were males. Tobacco smoking was the main risk factor in them. All the females had a history of exposure to biomass fuel in the form of firewood; none of them were smokers. Majority of patients (80.0%) had a history of one or more co-existing illnesses. Anemia was found to be an independent risk factor for mortality (adjusted hazard ratio: 3.167, 95% confidence interval: 1.516–6.616). Risk factors for poor outcome in COPD patients reported from other centers in India were not found to be relevant in this study.

Conclusions:

Anemia could be an independent risk factor for mortality in COPD patients. India already has a high prevalence of iron deficiency anemia especially in the rural area and in the geriatric population. Henceforth, family practitioners and primary care physicians may remain vigilant regarding the development of anemia in their COPD patients and institute remedial measures without delay. Futhermore, the wide variation reported in the predictors of outcome of COPD along with the finding of this study calls for an urgent need for more studies.