A comparison of generalist and pulmonologist care for patients hospitalized with severe chronic obstructive pulmonary disease: resource intensity, hospital costs, and survival. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment

Does uptake of specialty care affect HRQoL development in COPD patients beneficially? A difference-in-difference analysis linking claims and survey data

BACKGROUND

There is an evidence gap on whether the choice of specialty care beneficially affects health-related quality of life (HRQoL) in patients with chronic obstructive pulmonary disease (COPD). This study analyzes how newly initiated pulmonologist care affects the generic and disease-specific HRQoL in COPD patients over a period of 1 year.

METHODS

We linked claims data with data from two survey waves to investigate the longitudinal effect of specialty care on HRQoL using linear Difference-in-Difference models based on 1:3 propensity score matched data. Generic HRQoL was operationalized by EQ-5D-5L visual analog scale (VAS), and disease-specific HRQoL by COPD assessment test (CAT). Subgroup analyses examined COPD patients with low (GOLD AB) and high (GOLD CD) exacerbation risk.

RESULTS

In contrast to routine care patients, pulmonologists' patients (n = 442) experienced no significant deterioration in HRQoL (VAS - 0.0, p = 0.9870; CAT + 0.5, p = 0.0804). Models unveiled a small comparative advantage of specialty care on HRQoL (mean change: CAT - 0.8, VAS + 2.9), which was especially pronounced for GOLD AB (CAT - 0.7; VAS + 3.1).

CONCLUSION

The uptake of pulmonologist care had a statistically significant, but not clinically relevant, beneficial impact on the development of HRQoL by slowing down overall HRQoL deterioration within 1 year. Including specialty care more appropriately in COPD management, especially at lower disease stages (GOLD AB), could thus improve patients' health outcome.

Healthcare Utilization in Patients with Chronic Obstructive Pulmonary Disease Discharged from Coronavirus 2019 Hospitalization

Rationale

There is concern that patients with chronic obstructive pulmonary disease (COPD) are at greater risk of increased healthcare utilization (HCU) following Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-COV-2) infection.

Objective

To assess whether COPD is an independent risk factor for increased post-discharge HCU.

Methods

We conducted a retrospective cohort study of patients with COPD discharged home from a hospitalization due to Coronavirus Disease 2019 (COVID-19) between April 1, 2020, and March 31, 2021, using Optum's de-identified Clinformatics® Data Mart Database (CDM). COVID-19 was identified by an International Classification of Diseases, tenth revision, clinical modification (ICD-10-CM) diagnosis code of U07.1. The primary outcome was HCU (ie, emergency department (ED) visits, readmissions, rehabilitation/skilled nursing facility (SNF) visits, outpatient office visits, and telemedicine visits) nine months post-discharge after COVID-19 hospitalization (from here on "post-discharge") in patients with COPD compared to HCU of patients without COPD. Poisson regression modeling was used to calculate relative risk (RR) and confidence interval (CI) for COPD, adjusted for the other covariates.

Results

We identified a cohort of 160,913 patients hospitalized with COVID-19, with 57,756 discharged home and 14,622 (25.3%) diagnosed with COPD. Patients with COPD had a mean age of 75.48 years (±9.49); 55.5% were female and 70.9% were White. Patients with COPD had an increased risk of HCU in the nine months post-discharge after adjusting for the other covariates. Risk of ED visits, readmissions, length of stay during readmission, rehabilitation/SNF visits, outpatient office visits, and telemedicine visits were increased by 57% (RR 1.57; 95% CI 1.53-1.60), 50% (RR 1.50; 95% CI 1.46-1.54), 55% (RR 1.55; 95% CI 1.53-1.56), 18% (RR 1.18; 95% CI 1.14-1.22), 16% (RR 1.16; 95% CI 1.16-1.17), and 28% (RR 1.28; 95% CI 1.24-1.31), respectively. Younger patients (ages 18 to 65 years), women, and Hispanic patients with COPD showed an increased risk for post-discharge HCU.

Conclusion

Patients with COPD hospitalized with COVID-19 experienced increased HCU post-discharge compared to patients without COPD.

Utilization and determinants of use of non-pharmacological interventions in COPD: Results of the COSYCONET cohort

BACKGROUND

Guidelines for chronic obstructive pulmonary disease (COPD) recommend supplementing pharmacotherapy with non-pharmacological interventions. Little is known about the use of such interventions by patients. We analyzed the utilization of a number of non-pharmacological interventions and identified potential determinants of use.

METHODS

Based on self-reports, use of interventions (smoking cessation, influenza vaccination, physiotherapy, sports program, patient education, pulmonary rehabilitation) and recommendation to use were assessed in 1410 patients with COPD. The utilization was analyzed according to sex and severity of disease. Potential determinants of utilization included demographic variables and disease characteristics and were analyzed using logistic regression models.

RESULTS

Influenza vaccination in the previous autumn/winter was reported by 73% of patients. About 19% were currently participating in a reimbursed sports program, 10% received physiotherapy, 38% were ever enrolled in an educational program, and 34% had ever participated in an outpatient or inpatient pulmonary rehabilitation program. Out of 553 current or former smokers, 24% had participated in a smoking cessation program. While reports of having received a recommendation to use mainly did not differ according to sex, women showed significantly (p < 0.05) higher utilization rates than men for all interventions except influenza vaccination. Smoking was a predictor for not having received a recommendation for utilization and also significantly associated with a reduced odds of utilization. We found a correlation between recommendation to use and utilization.

CONCLUSIONS

Utilization of non-pharmacological interventions was lower in men and smokers. A recommendation or offer to use by the physician could help to increase uptake.

Comparison of specialist and generalist care

Objective The choice of whether to admit under a specialist or a generalist unit is often made with neither clear rationale nor understanding of its consequences. The present study compared the characteristics and outcomes of patients admitted with community-acquired pneumonia to either a general medicine or respiratory unit. Methods This study was a retrospective cross-sectional study using data from public hospitals in Adelaide, South Australia. Over 5 years there were 9775 overnight, unplanned appropriate adult admissions. Patient length of hospital stay, in-patient mortality rate and 30-day unplanned readmission rate were calculated, with and without adjustment for patient age and comorbidity burden. Results Over 80% of these patients were cared for by a general medicine unit rather than a specialist unit. Patients admitted to a general medicine unit were, on average, 4 years older than those admitted to a respiratory unit. Comorbidity burdens were similar between units at the same hospital. Length of in-patient stay was >1 day shorter for those admitted to a general medicine unit, without significant compromise in mortality or readmission rates. Between each hospital, general medicine units showed a range of mortality rates and length of hospital stay, for which there was no obvious explanation. Conclusions Compared with speciality care, general medicine units can safely and efficiently care for patients presenting to hospital with community-acquired pneumonia. What is known about the topic? Within the narrow range of any specific disease, generalist medical services are often cited as inferior in performance compared with a speciality service. This has implications for hospital resourcing, including both staffing and ward allocation. What does this paper add? This paper demonstrates that most patients admitted with a principal diagnosis of community-acquired pneumonia were admitted to a generalist unit and did not apparently fare worse than patients admitted to a specialist service; patients admitted to a generalist unit spent less time in hospital and there was no difference in mortality or readmission rate compared with patients admitted to a specialist service. What are the implications for practitioners? The provision of generalist services at urban hospitals in Australia provides a safe alternative admission option for patients presenting with pneumonia, and possibly for other common acute medical conditions.

Treatment decisions in end-stage COPD: who decides how? A cross-sectional survey of different medical specialties

INTRODUCTION

End-stage chronic obstructive pulmonary disease (COPD) patients with acute respiratory failure are often treated by representatives from different medical specialties. This study investigates if the choice of treatment is influenced by the medical specialty.

METHODS

An online cross-sectional survey among four Austrian medical societies was performed, accompanied by a case vignette of a geriatric end-stage COPD patient with acute respiratory failure. Respondents had to choose between noninvasive ventilation (NIV), a conservative treatment attempt (without NIV) and a palliative approach. Ethical considerations and their impact on decision making were also assessed.

RESULTS

Responses of 162 physicians (67 from intensive care units (ICUs), 51 from pulmonology or internal departments and 44 from geriatric or palliative care) were included. The decision for NIV (instead of a conservative or palliative approach) was associated with working in an ICU (OR 14.9, 95% CI 1.87-118.8) and in a pulmonology or internal department (OR 9.4, 95% CI 1.14-78.42) compared with working in geriatric or palliative care (Model 1). The decision for palliative care was negatively associated with working in a pulmonology or internal department (OR 0.16, 95% CI 0.05-0.47) and (nonsignificantly) in an ICU (OR 0.41, 95% CI 0.15-1.12) (Model 2).

CONCLUSIONS

Department association was shown to be an independent predictor for treatment decisions in end-stage COPD with acute respiratory failure. Further research on these differences and influential factors is necessary.

Concomitant pulmonologist and primary care for chronic obstructive pulmonary disease: a population study

BACKGROUND

Pulmonologists provide quality care, however, their number is not adequate to take care of all the chronic obstructive pulmonary disease (COPD) needs of the population and their services come with a cost. Their optimal role should be defined, ideally based on evidence, to ensure that their abilities are applied most efficiently where needed.

OBJECTIVE

To determine if concomitant pulmonologist and primary care physician care after COPD hospital or emergency department discharge was associated with better health outcomes than primary care services alone.

METHODS

A population cohort study was conducted in Ontario, Canada from 2004 to 2011. All individuals with a COPD hospital or emergency department discharge were included. Patients who visited both a pulmonologist and a primary care physician within 30 days of the index discharge were matched to patients who had visited a primary care physician alone using propensity scores. The composite outcome of death, COPD hospitalization or COPD emergency department visit was compared using proportional hazards regression.

RESULTS

In the propensity score matched sample, 39.7% of patients who received concomitant care and 38.9% who received primary care only died or visited the emergency department visit or hospital for COPD within 1 year (adjusted hazard ratio 1.08, 95% confidence interval 1.00-1.17). The former, however, were more likely to receive diagnostic testing and medications.

CONCLUSION

Patients who received concomitant care after COPD emergency department or hospital discharge did not have better outcomes than those who received primary care alone, however, they did receive more testing and medical management.

Geographic Accessibility of Pulmonologists for Adults With COPD: United States, 2013

BACKGROUND

Geographic clusters in prevalence and hospitalizations for COPD have been identified at national, state, and county levels. The study objective is to identify county-level geographic accessibility to pulmonologists for adults with COPD.

METHODS

Service locations of 12,392 practicing pulmonologists and 248,160 primary care physicians were identified from the 2013 National Provider Identifier Registry and weighted by census block-level populations within a series of circular distance buffer zones. Model-based county-level population counts of US adults ≥ 18 years of age with COPD were estimated from the 2013 Behavioral Risk Factor Surveillance System. The percentages of all estimated adults with potential access to at least one provider type and the county-level ratio of adults with COPD per pulmonologist were estimated for selected distances.

RESULTS

Most US adults (100% in urbanized areas, 99.5% in urban clusters, and 91.7% in rural areas) had geographic access to a primary care physician within a 10-mile buffer distance; almost all (≥ 99.9%) had access to a primary care physician within 50 miles. At least one pulmonologist within 10 miles was available for 97.5% of US adults living in urbanized areas, but only for 38.3% in urban clusters and 34.5% in rural areas. When distance increased to 50 miles, at least one pulmonologist was available for 100% in urbanized areas, 93.2% in urban clusters, and 95.2% in rural areas. County-level ratios of adults with COPD per pulmonologist varied greatly across the United States, with residents in many counties in the Midwest having no pulmonologist within 50 miles.

CONCLUSIONS

County-level geographic variations in pulmonologist access for adults with COPD suggest that those adults with limited access will have to depend on care from primary care physicians.

Type of attending physician influenced feeding tube insertions for hospitalized elderly people with severe dementia

Striking variation has been documented in the rates of feeding tube insertion for hospitalized patients with advanced dementia. This occurs despite the harms of the procedure, which may outweigh its benefits, and the procedure's inconsistency with care focused on the patient's comfort. Among nursing home residents with advanced dementia who were hospitalized in 2001-10 with an infection or dehydration, we found that rates of insertion of a percutaneous endoscopic gastrostomy feeding tube varied by type of attending physician. Insertion rates were markedly lower when all of a patient's attending physicians were hospitalists (1.6 percent) or nonhospitalist generalists (2.2 percent), compared to all subspecialists (11.0 percent) or a mixture of physicians by type, which typically included a subspecialist (15.6 percent). The portion of patients seen by a mixture of attending physicians increased from 28.9 percent in 2001 to 38.3 percent in 2010. Efforts to improve decision making in the care of patients with advanced dementia should include interventions to improve communication among physicians and the education of subspecialists about the merits of using feeding tubes with this population.

Use patterns of long-acting bronchodilators in routine COPD care: the OUTPUL study

BACKGROUND

COPD is the fourth leading cause of death in the world. In the case of exacerbations or persistent symptoms, regular treatment with long-acting bronchodilators is recommended to control the symptoms, reduce exacerbations and improve health status. Objectives. To describe patterns of drug utilization among patients diagnosed with COPD, to measure continuity with long-acting bronchodilators, to identify determinants of not receiving long-acting therapy continuously.

METHODS

We identified a cohort of patients discharged from hospital with diagnosis of COPD between 2006 and 2008. Patients were observed for a two-year follow-up period, starting from the day of discharge. Follow-up was segmented in six-month periods, in order to dynamically evaluate prescription patterns of Long-Acting Beta-Agonists (LABA), tiotropium, and inhaled corticosteroids. Patients with prescriptions for LABA and/or tiotropium in each of the six-month periods were defined as "continuously treated with long-acting bronchodilators." The degree of drug treatment coverage was measured through the Medication Possession Ratio (MPR). Logistic regression was performed to identify determinants of not receiving long-acting bronchodilators continuously.

RESULTS

A total of 11,452 patients diagnosed with COPD were enrolled. Only 34.8% received long-acting bronchodilators continuously. The MPR was greater than 75% in 19.6% of cases. Among the determinants of not receiving long-acting bronchodilators continuously, older age and co-morbidities played an important role.

CONCLUSIONS

In clinical practice, the COPD pharmacotherapy is not consistent with clinical guidelines. Medical education is needed to disseminate evidence-based prescribing patterns for COPD, and to raise awareness among physicians and patients on the health benefits of an appropriate pharmacological treatment.

Guidelines for diagnosis and management of chronic obstructive pulmonary disease: Joint ICS/NCCP (I) recommendations

Chronic obstructive pulmonary disease (COPD) is a major public health problem in India. Although several International guidelines for diagnosis and management of COPD are available, yet there are lot of gaps in recognition and management of COPD in India due to vast differences in availability and affordability of healthcare facilities across the country. The Indian Chest Society (ICS) and the National College of Chest Physicians (NCCP) of India have joined hands to come out with these evidence-based guidelines to help the physicians at all levels of healthcare to diagnose and manage COPD in a scientific manner. Besides the International literature, the Indian studies were specifically analyzed to arrive at simple and practical recommendations. The evidence is presented under these five headings: (a) definitions, epidemiology, and disease burden; (b) disease assessment and diagnosis; (c) pharmacologic management of stable COPD; (d) management of acute exacerbations; and (e) nonpharmacologic and preventive measures. The modified grade system was used for classifying the quality of evidence as 1, 2, 3, or usual practice point (UPP). The strength of recommendation was graded as A or B depending upon the level of evidence.

Factors associated with medication adherence in patients with chronic obstructive pulmonary disease

BACKGROUND

Predictors of medication adherence are not well known in chronic obstructive pulmonary disease (COPD). It is therefore necessary to identify factors associated with adherence to improve the effectiveness of COPD management within real-world situations.

OBJECTIVES

The goals of this study were to estimate adherence to respiratory medication and to identify factors related to adherence in COPD patients.

METHODS

This was an observational, cross-sectional study conducted on a sample of COPD outpatients. The following information was obtained: adherence to respiratory therapy (Morisky Medication Adherence Scale), age, gender, smoking status, COPD severity [Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage], lung function [post-bronchodilator forced expiratory volume in 1 s (FEV(1))], treatment regimen for COPD, COPD medication costs per month paid by the patient and health-related quality of life (EuroQol 5-dimension questionnaire). A multivariate logistic regression analysis was performed to identify the independent predictors of adherence.

RESULTS

Of the 170 participants (mean age 63.8 years, 41.8% male), 58.2% reported optimal adherence. Adherence to respiratory therapy was associated with age, current smoking status, number of respiratory drugs, number of daily respiratory drug doses and quality of life (p < 0.005). Adherence to respiratory therapy was not related to gender, GOLD stage, FEV(1) or COPD medication costs.

CONCLUSIONS

Adherence to COPD medication regimens is poor. Less frequent dosing regimens could be an effective method to enhance adherence to respiratory therapy. Quality-of-life monitoring within clinical practice settings could facilitate improved medication adherence.

Compliance and persistence with medication in chronic obstructive pulmonary disease

A gyógyszeres kezelés hiányos compliance-e, valamint perzisztenciája jelentős problémát jelent a krónikus obstruktív tüdőbetegek optimális terápiájának kialakításában – derül ki a szerzők szisztematikus irodalomelemzéséből. A túlzott gyógyszerhasználat ugyanúgy, mint a csökkent gyógyszerbevitel inadekvát terápiát meghatározó fontos tényező. A beteg-együttműködés hiánya jelentősen növeli az exacerbatiók előfordulását, a kórházi kezelések számát, a mortalitási rátát, valamint csökkenti a betegek életminőségét. Célszerű a betegjellemzőket, a várható compliance-t, illetve perzisztenciát már a gyógyszer kiválasztásakor figyelembe venni. Hatékonyabb orvos–beteg kapcsolattal, megfelelő betegtájékoztatással ugyancsak javítható a kezelések hatékonysága.

Self-management for breathlessness in COPD: the role of pulmonary rehabilitation

Most of the effort of controlling breathlessness happens at home. Therefore, it is important to explore how patients and carers respond to breathlessness, what their self-care entails and what they experience as helpful. Data were collected from a purposive sample of 18 chronic obstructive pulmonary disease patients through participant observation during outpatient consultations and in-depth interviews at a large hospital and in the community in London. Data were analysed with the Grounded Theory approach. As information regarding the management of breathlessness was lacking and access to treatment was difficult, patients reverted to alternative strategies. Some patients developed considerable expertise and managed their symptoms competently within the limits of current care. Patients who coped successfully were involved in pulmonary rehabilitation and had adopted this as a way of life. Benefits and challenges to participation in these programmes were identified. Those patients who self-manage maintain an acceptable quality of life through self-acquired expertise relating to symptoms, medication and help-seeking. Well-being needs to be understood not as the end point, but as a precarious balance needing skilful maintenance and hard work. The findings have implications for notions such as adherence, patient involvement and responsibility in the management of chronic obstructive pulmonary disease.

Multidisciplinary care of the patient with chronic obstructive pulmonary disease

The National Emphysema Treatment Trial used a multidisciplinary team approach to implement the maximum medical care protocol, including adjustment of medications and outpatient pulmonary rehabilitation for all patients and nutritional and psychological counseling as needed. This article discusses the benefits of such an approach in the care of the patient with chronic obstructive pulmonary disease. Team member roles complement each other and contribute to the goal of providing the highest-quality medical care. The primary focus of the team is to reinforce the medical plan and to provide patient education and support. This article reviews the elements of the initial patient assessment and the functional and nutritional assessment. Patient education focuses on medication use, recognition and management of chronic obstructive pulmonary disease exacerbation symptoms, smoking cessation, advance directives, and travel.

Mortality of elderly patients in Ontario after hospital admission for chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is associated with significant mortality. It is currently the fourth leading cause of death in Canada and the world.

OBJECTIVES

To describe the mortality of elderly patients in Ontario after hospital admission for COPD.

METHODS

A retrospective cohort study was conducted using the Discharge Abstract Database from the Canadian Institute for Health Information. Patients aged 65 years and older who were admitted to hospital between 2001 and 2004 with primary discharge diagnoses labelled with International Classification of Diseases, Ninth Revision codes 491, 492 and 496 were included in the study.

RESULTS

Mortality rates were 8.81, 12.10, 14.53 and 27.72 per 100 COPD hospital admissions at 30, 60, 90 and 365 days after hospital discharge, respectively. Mortality also increased with age, and men had higher rates than women. No significant differences in mortality rates were found between different socioeconomic groups (P>0.05). Patients with shared care of a family physician or general practitioner and a specialist had significantly lower mortality rates than the overall rate (P<0.05), and their rates were approximately one-half the rate of patients with only one physician.

CONCLUSIONS

Hospitalization with COPD is associated with significant mortality. Patients who were cared for by both a family physician or general practitioner and a specialist had significantly lower mortality rates than those cared for by only one physician, suggesting that continuous and coordinated care results in better survival.

Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary

Chronic obstructive pulmonary disease (COPD) remains a major public health problem. It is the fourth leading cause of chronic morbidity and mortality in the United States, and is projected to rank fifth in 2020 in burden of disease worldwide, according to a study published by the World Bank/World Health Organization. Yet, COPD remains relatively unknown or ignored by the public as well as public health and government officials. In 1998, in an effort to bring more attention to COPD, its management, and its prevention, a committed group of scientists encouraged the U.S. National Heart, Lung, and Blood Institute and the World Health Organization to form the Global Initiative for Chronic Obstructive Lung Disease (GOLD). Among the important objectives of GOLD are to increase awareness of COPD and to help the millions of people who suffer from this disease and die prematurely of it or its complications. The first step in the GOLD program was to prepare a consensus report, Global Strategy for the Diagnosis, Management, and Prevention of COPD, published in 2001. The present, newly revised document follows the same format as the original consensus report, but has been updated to reflect the many publications on COPD that have appeared. GOLD national leaders, a network of international experts, have initiated investigations of the causes and prevalence of COPD in their countries, and developed innovative approaches for the dissemination and implementation of COPD management guidelines. We appreciate the enormous amount of work the GOLD national leaders have done on behalf of their patients with COPD. Despite the achievements in the 5 years since the GOLD report was originally published, considerable additional work is ahead of us if we are to control this major public health problem. The GOLD initiative will continue to bring COPD to the attention of governments, public health officials, health care workers, and the general public, but a concerted effort by all involved in health care will be necessary.

Do emergency department patients with possible acute coronary syndrome have better outcomes when admitted to cardiology versus other services?

STUDY OBJECTIVE

Emergency physicians need to consider potential differences in quality of care across admitting services in their triage decisions. For emergency department (ED) patients with possible acute coronary syndrome who require hospitalization, there are relatively few data to guide emergency physicians in deciding whether admission to a cardiology service bed yields better outcomes than admission to a noncardiology service.

METHODS

We enrolled 544 ED patients who were admitted for symptoms of possible acute coronary syndrome after a nondiagnostic initial evaluation during a quality improvement trial at 2 university hospitals. Adverse events, inhospital treatment, and follow-up care were assessed by 30-day telephone interview and medical record review. We used a modified version of the Medical Outcomes Study Short Form 20 and the Duke Activity Status Index to assess functional status. To account for selection bias, we analyzed process and outcome variables after adjustment for the estimated propensity of being admitted to cardiology and predicted probability of acute cardiac ischemia.

RESULTS

Overall, 34% of admitted patients had confirmed acute coronary syndrome. Patients admitted to a cardiology service were significantly more likely to undergo evaluation for ischemic heart disease than those admitted to a noncardiology service (adjusted odds ratio for noninvasive testing 2.7; 95% confidence interval 1.7 to 4.2) but were not more likely to receive recommended therapies. The incidence of ED revisits and rehospitalizations, functional status, and adverse cardiovascular events were similar in both groups.

CONCLUSION

ED patients admitted for evaluation of possible acute coronary syndrome do not experience worsened short-term outcomes if admitted to a noncardiology service bed.

Cigarette smoke impacts immune inflammatory responses to influenza in mice

RATIONALE

Studies have shown that cigarette smoke impacts respiratory host defense mechanisms; however, it is poorly understood how these smoke-induced changes impact the overall ability of the host to deal with pathogenic agents.

OBJECTIVE

The objective of this study was to investigate the impact of mainstream cigarette smoke exposure on immune inflammatory responses and viral burden after respiratory infection with influenza A.

METHODS

C57BL/6 mice were sham- or smoke-exposed for 3 to 5 mo and infected with either 2.5 x 10(3) pfu (low dose) or 2.5 x 10(5) pfu (high dose) influenza virus.

MEASUREMENTS AND MAIN RESULTS

Although smoke exposure attenuated the airway's inflammatory response to low-dose infection, we observed increased inflammation in smoke-exposed compared with sham-exposed mice after infection with high-dose influenza, despite a similar rate of viral clearance. The heightened inflammatory response was associated with increased expression of tumor necrosis factor-alpha, interleukin-6, and type 1 IFN in the airway, and increased mortality. Importantly, smoke exposure did not interfere with the development of influenza-specific memory responses; sham- and smoke-exposed animals were equally protected upon viral rechallenge.

CONCLUSION

Our study suggests that, in mice, cigarette smoke affects primary antiviral immune-inflammatory responses, whereas secondary immune protection remains intact.

A review of the application of propensity score methods yielded increasing use, advantages in specific settings, but not substantially different estimates compared with conventional multivariable methods

OBJECTIVE

Propensity score (PS) analyses attempt to control for confounding in nonexperimental studies by adjusting for the likelihood that a given patient is exposed. Such analyses have been proposed to address confounding by indication, but there is little empirical evidence that they achieve better control than conventional multivariate outcome modeling.

STUDY DESIGN AND METHODS

Using PubMed and Science Citation Index, we assessed the use of propensity scores over time and critically evaluated studies published through 2003.

RESULTS

Use of propensity scores increased from a total of 8 reports before 1998 to 71 in 2003. Most of the 177 published studies abstracted assessed medications (N=60) or surgical interventions (N=51), mainly in cardiology and cardiac surgery (N=90). Whether PS methods or conventional outcome models were used to control for confounding had little effect on results in those studies in which such comparison was possible. Only 9 of 69 studies (13%) had an effect estimate that differed by more than 20% from that obtained with a conventional outcome model in all PS analyses presented.

CONCLUSIONS

Publication of results based on propensity score methods has increased dramatically, but there is little evidence that these methods yield substantially different estimates compared with conventional multivariable methods.

Do Clinical Marker States Improve Responsiveness and Construct Validity of the Standard Gamble and Feeling Thermometer: A Randomized Multi-Center Trial in Patients with Chronic Respiratory Disease

BACKGROUND

Optimizing the validity and responsiveness of utility measures will enhance their usefulness in randomized trials. We evaluated the impact of clinical marker state (CMS) rating prior to patients' rating their own health on two utility instruments (feeling thermometer (FT) and standard gamble (SG)) in patients with chronic respiratory disease (CRD).

METHODS

We randomized 182 patients with CRD to complete the FT (self-administered) and SG with CMS (FT+/SG+, n=91) or without marker states (FT-/SG-, n=91) before and after undergoing respiratory rehabilitation in a multi-center trial.

RESULTS

Use of CMS did not influence baseline utility scores. Improvement after therapy on the scale from 0 (dead) to 1.0 (full health) was 0.04 both in FT+ (p=0.03) and FT- (p=0.02; the difference between FT+ and FT- was 0.00, p=0.83). Improvement on the SG was 0.05 in both SG+ (p=0.08) and SG- (p=0.04; difference between SG+ and SG- 0.00, p=0.95). Correlations with other health related quality of life scores were highest for FT+.

CONCLUSION

Administration of CMS did not improve responsiveness of the FT but may have improved construct validity. The SG showed limited construct validity and responsiveness that was not influenced by CMS use.

Factors associated with medication nonadherence in patients with COPD

STUDY OBJECTIVES

To identify the predictors of medication adherence in patients with COPD and contrast the health beliefs, experiences, and behaviors of COPD patients self-reporting good adherence with those of patients reporting suboptimal adherence to their medications.

DESIGN

Cross-sectional self-administered questionnaire.

SETTING

Ambulatory care.

PARTICIPANTS

Patients with chronic respiratory ailments identified through respiratory support groups and from a pulmonary rehabilitation database.

MEASUREMENTS AND RESULTS

A 30-item questionnaire comprising items pertaining to health beliefs, experiences, and behaviors along with a valid self-reported measure of adherence-the medication adherence report scale (MARS)-was administered to 525 ambulatory patients with chronic lung conditions. A total of 276 usable responses were received (52.6%). The mean age of the respondents was 71 years, and there were slightly more male patients (54.4%). COPD was the underlying disease condition in 90.6% of the respondents; two thirds of the respondents had comorbid conditions. The respiratory condition was managed by both general practitioners and respiratory specialists in 61.2% of cases. One third of the respondents self-reported complementary and alternative medicine use. The mean score (+/- SD) on the MARS among the respondents was 23.37 +/- 2.09. One hundred two patients self-reported perfect adherence on the MARS. Differences in knowledge about the illness and treatment, faith in and satisfaction with the treatment and doctors, concerns about the treatment, and intentional and unintentional deviations from the recommended treatment were detected between the adherent and less adherent groups. In multivariate analysis, "I vary my recommended management based on how I am feeling" and "I get confused about my medications" were found to be significant independent predictors of nonadherence.

CONCLUSIONS

Patients' acceptance of the disease process and recommended treatment, knowledge about and faith in the treatment, effective patient-clinician interaction, and routinization of drug therapy are critical for optimal medication adherence in patients with COPD.

Do consultants differ? Inferences drawn from hospital in-patient enquiry (HIPE) discharge coding at an Irish teaching hospital

OBJECTIVE

To find out if there was a difference between hospital consultants, all trained in acute general medicine, in length of stay (LOS), re-admission rates, resource utilisation, and diagnostic coding, among patients admitted as emergencies to St James' Hospital (SJH) Dublin.

METHODS

A retrospective analysis was performed of data on discharges from hospital, recorded in the hospital in-patient enquiry (HIPE) system, relating to 9204 episodes among 6968 emergency medical patients admitted to SJH between 1 January 2002 and 31 October 2003. For comparative analysis, four physician groups were defined consisting of gastroenterology (GI, n = 4), respiratory (n = 3), general internal medicine (GIM, n = 2), or specialty (n = 5).

RESULTS

GIM consultants had the shortest LOS (median 5 days); GIM and respiratory consultants were less likely to have long stay patients (> 30 days, p<0.0001). Patients re-admitted under the same consultant had a longer LOS than those re-admitted under a different consultant (p<0.0001). Endoscopy and GI radiology investigations were used most by GI consultants, computed tomography of the thorax by respiratory, ECHO by respiratory and specialty, and computed tomography of brain by GIM and specialty consultants. GI diagnostic codings were more frequent with GI consultants (p<0.0001), respiratory diagnoses and malignancy with respiratory (p<0.0001 for both), diabetes and hypertension with specialty (p = 0.0017), and heart failure more with GIM consultants (p = 0.001).

CONCLUSIONS

This study found that the HIPE database was very powerful in predicting differences between hospital consultants in LOS, re-admission rates, resource utilisation, and disease coding. It would be of interest to examine the extent to which protocols and guidelines could reduce such variations.

Propensity score methods gave similar results to traditional regression modeling in observational studies: a systematic review

OBJECTIVE

To determine whether adjusting for confounder bias in observational studies using propensity scores gives different results than using traditional regression modeling.

METHODS

Medline and Embase were used to identify studies that described at least one association between an exposure and an outcome using both traditional regression and propensity score methods to control for confounding. From 43 studies, 78 exposure-outcome associations were found. Measures of the quality of propensity score implementation were determined. The statistical significance of each association using both analytical methods was compared. The odds or hazard ratios derived using both methods were compared quantitatively.

RESULTS

Statistical significance differed between regression and propensity score methods for only 8 of the associations (10%), kappa = 0.79 (95% CI = 0.65-0.92). In all cases, the regression method gave a statistically significant association not observed with the propensity score method. The odds or hazard ratio derived using propensity scores was, on average, 6.4% closer to unity than that derived using traditional regression.

CONCLUSIONS

Observational studies had similar results whether using traditional regression or propensity scores to adjust for confounding. Propensity scores gave slightly weaker associations; however, many of the reviewed studies did not implement propensity scores well.

Cigarette smoke decreases pulmonary dendritic cells and impacts antiviral immune responsiveness

We investigated the impact of cigarette smoke exposure on respiratory immune defense mechanisms. Mice were exposed to two cigarettes daily, 5 d/wk, for 2-4 mo. Tobacco smoke decreased the number of dendritic cells (DCs) in the lung tissue. Furthermore, smoke exposure dramatically reduced the percentage of B7.1-expressing DCs. Because DCs are believed to be indispensable to the initiation of adaptive immune responses, we investigated the impact of cigarette smoke on immune responsiveness toward adenovirus. Mice were exposed to two cigarettes for 2-4 mo and inoculated with 2 x 10(8) pfu of a replication-deficient adenovirus on three occasions, 2 wk apart, during the last month of tobacco smoke exposure. Smoke exposure specifically prevented the expansion and maximal activation of CD4 T cells and reduced the number of both activated CD4 and CD8 T cells. Consequently, smoke exposure shifted the activated CD4:CD8 T cell ratio from 3 to 1.5 when compared with sham exposure. Significant decreases were also observed in serum adenovirus-specific pan IgG, IgG1, and IgG2a immunoglobulin levels, which was associated with diminished viral neutralization capacity. We demonstrate that chronic tobacco smoke exposure impairs the immune response against adenovirus. This may, in part, explain the increased prevalence of viral infections in chronic obstructive pulmonary disease.

Length of ICU stay for chronic obstructive pulmonary disease varies among large community hospitals

OBJECTIVE

To determine whether differences exist among large community hospitals in length of Intensive Care Unit (ICU) stay, hospital stay or hospital mortality for patients admitted to ICU and whose most responsible diagnosis was chronic obstructive pulmonary disease (COPD).

DESIGN

Retrospective cohort study.

SETTING

All seven large community hospitals in British Columbia, Canada. PATIENTS. All 296 patients who were admitted to ICUs and whose most responsible diagnosis was COPD during the 3 fiscal years 1994-1997.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

After adjusting for age, gender, case-mix group, and co-morbidity, we found a significant difference in length of ICU stay for these patients among hospitals ( P <0.03). No differences were found in hospital mortality or length of hospital stay for the same patients among the same hospitals.

CONCLUSIONS

There is significant variation in length of ICU stay for patients who are admitted to ICU and whose most responsible diagnosis is COPD, among large community hospitals. These small area variations may point to opportunities to improve efficiency of care. Further prospective, detailed data collection is required to validate these observations and to identify factors responsible for any differences found.

Risk factors for hospitalization for a chronic obstructive pulmonary disease exacerbation. EFRAM study

Although exacerbation of chronic obstructive pulmonary disease (COPD) is important in terms of health and costs, there is little information about which are the risk factors. We estimated the association between modifiable and nonmodifiable potential risk factors of exacerbation and the admission for a COPD exacerbation, using a case-control approach. Cases were recruited among admissions for COPD exacerbation during 1 yr in four tertiary hospitals of the Barcelona area. Control subjects were recruited from hospital's register of discharges, having coincided with the referent case in a previous COPD admission but being clinically stable when the referent case was hospitalized. All patients completed a questionnaire and performed spirometry, blood gases, and physical examination. Information about potential risk factors was collected, including variables related to clinical status, characteristics of medical care, medical prescriptions, adherence to medication, lifestyle, quality of life, and social support. A total of 86 cases and 86 control subjects were included, mean age 69 yr, mean FEV(1) 39% of predicted. Multivariate logistic regression showed the following risk (or protective) factors of COPD hospitalization: three or more COPD admissions in the previous year (odds ratio [OR] 6.21, p = 0.008); FEV(1) (OR 0.96 per percentual unit, p < 0.0005); underprescription of long-term oxygen therapy (LTOT) (OR 22.64, p = 0.007); and current smoking (OR 0.30, p = 0.022). Among a wide range of potential risk factors we have found that only previous admissions, lower FEV(1), and underprescription of LTOT are independently associated with a higher risk of admission for a COPD exacerbation.

Effect of pediatric surgical practice on the treatment of children with appendicitis

OBJECTIVE

Acute appendicitis in children is managed by both general surgeons (GSs) and pediatric surgeons (PSs). Our objective was to investigate the economics of surgical care provided by either GSs or PSs for appendicitis.

METHODS

The outcome of children within our state who underwent operative treatment for appendicitis (January 1994 to June 1997) by board-certified GSs were compared with the results of PSs. Data were sorted according to patient age and diagnosis according to the International Classification of Diseases, Ninth Revision. Analysis of variance was performed on continuous data, and chi(2) analysis was performed on nominal data; data are depicted as mean +/- standard error of the mean.

RESULTS

GSs (n = 2178) managed older children when compared with PSs (n = 1018; 11.0 +/- 0.1 vs 9.1 +/- 0.1 years) and less frequently treated perforated appendicitis (18.8% vs 31.9%). Independent of diagnosis (simple or perforated appendicitis), younger children (0-4 years, 5-8 years, and 9-12 years) who were treated by PSs had a significantly shorter hospital stay and/or decreased hospital charge when compared with those who were treated by GSs. However, older children (13-15 years) seemed to have comparable outcomes.

CONCLUSIONS

Younger children with appendicitis have reduced hospital days and charges when they are treated by PSs.

An economic overview of chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a major cause of mortality and morbidity. Relatively few pharmacoeconomic studies have been conducted on this disease. This article reviews available information about the utilisation of healthcare resources and cost of care, and the cost or cost effectiveness of therapeutic interventions reported for this disease. Burden-of-illness data indicate that hospital care, medications and oxygen therapy were the major cost drivers in these studies. Mean annual Medicare expenditures in the US were $US11,841 (2000 values) for patients with COPD compared with $US4,901 for all covered patients. Utilisation was skewed; the most expensive 10% of the Medicare beneficiaries accounted for nearly 50% of total expenditures for this disease. Costs are associated with health status, age, physician specialty, geographic location and type of insurance coverage. Six types of interventions were assessed in the literature--pharmacotherapy, oxygen therapy, home care, surgery, exercise and rehabilitation and health education. The studies used different analytic strategies (e.g. cost-minimisation and cost-effectiveness analyses) and even within the realm of cost-effectiveness analyses, no uniformity existed as to how outcome was measured. Patient severity was not always delineated, and the length of the follow-up period, while quite short, varied. Only 11 of the 34 evaluations were based on randomised controlled trials. Cost-minimisation studies generally found no significant difference in the cost of antimicrobial treatment for first-line, second-line and third-line agents. Studies of bronchodilators indicated that ipratropium bromide alone or in combination with salbutamol (albuterol) was the preferred medication. The major area for achieving cost savings is by reducing hospital utilisation. As the annual rate of hospitalisation is relatively low, large patient samples will be required to demonstrate an economic advantage for a new therapy. The major challenges will be financing such a study, and selecting an outcome measure that satisfies both clinical and economic conventions.

Generalists and oncologists show similar care practices and outcomes for hospitalized late-stage cancer patients. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks for Treatment

OBJECTIVE

The objective of this work was to identify similarities and differences in primary attending physicians' (generalists' versus oncologists') care practices and outcomes for seriously ill hospitalized patients with malignancy.

DESIGN

This was a prospective cohort study (SUPPORT project).

SETTING

Subjects were recruited from 5 US teaching hospitals; data were gathered from 1989 to 1994.

SUBJECTS

Included in the study was a matched sample of 642 hospitalized patients receiving care for non-small-cell lung cancer, colon cancer metastasized to the liver, or multiorgan system failure associated with malignancy with either a generalist or an oncologist as the primary attending physician.

MEASUREMENTS

Care practices and patient outcomes were determined from hospital records. Length of survival was identified with the National Death Index. Physicians' perceptions of patient's prognosis, preference for cardiopulmonary resuscitation (CPR), and length of relationship were assessed by interview. A propensity score for receiving care from an oncologist was constructed. After propensity-based matching of patients, practices and outcomes of oncologists' and generalists' patients were assessed through group comparison techniques.

RESULTS

Generalist and oncologist attendings showed comparable care practices, including the number of therapeutic interventions, eg, "rescue care" and chemotherapy, and the number of care topics discussed with patients/ families. Length of stay, discharge to supportive care, readmission, total hospital costs, and survival rates were similar. For both physician groups, perception of patients' wish for CPR was associated with rescue care (P < 0.03), and such care was related to higher hospital costs (P < 0.000). Poorer prognostic estimates predicted aggressiveness-of-care discussions by both types of physicians. Length of the patient-doctor relationship was associated with oncologists' care practices. More documented discussion about aggressiveness of care was related to higher hospital costs and shorter survival for patients in both physician groups (P < 0.001).

CONCLUSIONS

Generalists and oncologists showed similar care practices and outcomes for comparable hospitalized late-stage cancer patients. Physicians' perceptions about patients' preferences for CPR and prognosis influenced decision making and outcomes for patients in both physician groups. Length of relationship with patients was associated only with oncologists' care practices. Rescue care increased hospital costs but had no effect on patient survival. Future studies should compare physicians' palliative care as well as acute-care practices in both inpatient and ambulatory care settings. Patients' end-of-life quality and interchange between physician groups should also be documented and compared.

Utilization in COPD: patient characteristics and diagnostic evaluation

STUDY OBJECTIVES

Information on current practices of COPD diagnosis and treatment is needed to identify opportunities for improving care. This study describes the clinical characteristics and diagnostic evaluations of COPD patients in a health maintenance organization (HMO) and a university-affiliated county medical center (UMC).

DESIGN

Cross-sectional survey performed in a 174,484-member regional HMO and in The University of New Mexico Hospitals and Clinics (UNMH).

PATIENTS

Two hundred COPD patients from each system randomly selected from administrative databases based on discharge diagnoses.

RESULTS

COPD patients in the UMC, compared to those in the HMO, were younger (mean age, 59.3 vs 66.9 years, respectively), were more likely to be using home oxygen (33% vs 20%, respectively), and had fewer chronic medical conditions (mean number of conditions, 3.1 vs 3.7, respectively) (p < 0.01 for all differences). Approximately half of the COPD patients in both groups continued to smoke cigarettes during the study year. Only 38% of patients in the HMO and 42% in the UNMH system had spirometry results documented in their medical records.

CONCLUSIONS

The demographic and clinical characteristics of the COPD patients in these two health-care systems were very different, but smoking status and utilization of diagnostic tests were similar. The diagnosis of COPD in most patients was based only on a history of chronic respiratory symptoms and smoking; spirometry often was not used to confirm the diagnosis. An increased emphasis on smoking cessation and more effective utilization of spirometry are needed to improve the management of COPD in these health-care systems.

A systematic review of the effects of physician specialty on the treatment of coronary disease and heart failure in the United States

PURPOSE

To assess the effects of physician specialty on the knowledge, management, and outcomes of patients with coronary disease or heart failure.

MATERIALS AND METHODS

We performed a systematic search of MEDLINE from 1980 to 1997, as well as bibliographic references to articles about the effects of physician specialty on the knowledge, treatment, and outcomes of patients with coronary disease or heart failure in the United States.

RESULTS

Twenty-four articles met our criteria for inclusion (including eight that involved knowledge or self-reported practices, 14 that described actual practice patterns, and six that measured clinical outcomes). Cardiologists were more knowledgeable than generalist physicians about the optimal evaluation and management of coronary disease but not about the use of angiotensin-converting enzyme (ACE) inhibitors for heart failure. Patients with unstable angina or myocardial infarction were more likely to receive proven medical therapies, and possibly had improved outcomes, if they were treated by cardiologists. The use of lipid-lowering drugs after myocardial infarction was also more common among patients of cardiologists. ACE inhibitor use for heart failure was probably greater, and short-term readmission rates were lower, with cardiology care.

CONCLUSIONS

Patients with coronary disease or heart failure in the United States who are treated by cardiologists appear more likely to receive evidence-based care and probably have better outcomes. Investigation of collaborative models of care and innovative efforts to improve the use of proven therapies by physicians are needed.

Resource use and survival of patients hospitalized with congestive heart failure: differences in care by specialty of the attending physician. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments

BACKGROUND

Previous studies suggest that specialty care is more costly but may produce improved outcomes for patients with acute cardiac illnesses.

OBJECTIVE

To determine whether patients with congestive heart failure who are cared for by cardiologists experienced differences in costs, care patterns, and survival compared with patients of generalists.

DESIGN

Prospective cohort study.

SETTING

5 U.S. teaching hospitals between 1989 and 1994.

PATIENTS

1298 patients hospitalized with an exacerbation of congestive heart failure.

MEASUREMENTS

Hospital costs; average daily Therapeutic Intervention Scoring System (TISS) score; and survival censored at 30, 180, and 365 days and 31 December 1994.

RESULTS

Compared with patients of generalists, patients of cardiologists were younger (mean age, 63.3 and 71.4 years; P < 0.001) and had lower Acute Physiology Scores at the time of admission (35.1 and 36.7; P < 0.001) but were more likely to have a history of ventricular arrhythmias (21.0% and 10.2%; P < 0.001). At 6 months, 201 (27%) patients of cardiologists and 149 (27%) patients of generalists had died. After adjustment for sociodemographic characteristics and severity of illness, patients of cardiologists incurred costs that were 42.9% (95% CI, 27.8% to 59.8%) higher and average daily TISS scores that were 2.83 points (CI, 1.96 to 3.68 points) higher than those of patients of generalists. Patients of cardiologists were more likely to undergo right-heart catheterization (adjusted odds ratio, 2.9 [CI, 1.7 to 4.9]) or cardiac catheterization (adjusted odds ratio, 3.9 [CI, 2.4 to 6.2]) and had higher odds for transfer to an intensive care unit and electrocardiographic monitoring. Adjusted survival did not differ significantly between groups at 30 days; however, there was a trend toward improved survival among patients of cardiologists at 1 year (adjusted relative hazard, 0.82 [CI, 0.65 to 1.04]) and at maximum follow-up (adjusted relative hazard, 0.80 [CI, 0.66 to 0.96]).

CONCLUSIONS

In this observational study of patients hospitalized with congestive heart failure, cardiologist care was associated with greater costs and resource use and no difference in survival at 30 days of follow-up. Whether the trend toward better survival at longer follow-up represents differences in care or unadjusted illness severity is uncertain.