Comorbidities and length of stay in chronic obstructive pulmonary disease patients

Predictors of Length of Stay, Mortality and Rehospitalization in COPD Patients: A Retrospective Cohort Study

Chronic obstructive pulmonary disease (COPD) is a highly prevalent chronic lung disease that has a significant impact on individuals and healthcare systems worldwide. This study aimed to identify factors that predict the length of a hospital stay (LOHS), one-year mortality, and rehospitalization within 6 months in patients admitted for acute exacerbation of COPD (AECOPD). A retrospective cohort study was conducted using data from 170 patients admitted to a district general hospital in Switzerland between January 2019 and February 2020. Sociodemographic and health-related variables measured at admission were analyzed as potential predictors. Multivariable zero-truncated negative binomial and logistic regression analyses were performed to assess the risk factors for LOHS (primary endpoint), mortality, and rehospitalization. The results show that an indication for oxygen supplementation was the only significant predictor of LOHS. In the logistic regression analysis, older age, COPD severity stages GOLD III and IV, active cancer and arrhythmias were associated with higher mortality, whereas rehabilitation after discharge was associated with lower mortality. There were no significant associations regarding rehospitalization. This study identified routinely available predictors for LOHS and mortality, which may further advance our understanding of AECOPD and thereby improve patient management, discharge planning, and hospital costs. The protective effect of rehabilitation after hospitalization regarding lower mortality warrants further confirmation and may improve the comprehensive management of patients with AECOPD.

A risk nomogram for predicting prolonged intensive care unit stays in patients with chronic obstructive pulmonary disease

Background

Providing intensive care is increasingly expensive, and the aim of this study was to construct a risk column line graph (nomograms)for prolonged length of stay (LOS) in the intensive care unit (ICU) for patients with chronic obstructive pulmonary disease (COPD).

Methods

This study included 4,940 patients, and the data set was randomly divided into training (n = 3,458) and validation (n = 1,482) sets at a 7:3 ratio. First, least absolute shrinkage and selection operator (LASSO) regression analysis was used to optimize variable selection by running a tenfold k-cyclic coordinate descent. Second, a prediction model was constructed using multifactorial logistic regression analysis. Third, the model was validated using receiver operating characteristic (ROC) curves, Hosmer-Lemeshow tests, calibration plots, and decision-curve analysis (DCA), and was further internally validated.

Results

This study selected 11 predictors: sepsis, renal replacement therapy, cerebrovascular disease, respiratory failure, ventilator associated pneumonia, norepinephrine, bronchodilators, invasive mechanical ventilation, electrolytes disorders, Glasgow Coma Scale score and body temperature. The models constructed using these 11 predictors indicated good predictive power, with the areas under the ROC curves being 0.826 (95%CI, 0.809-0.842) and 0.827 (95%CI, 0.802-0.853) in the training and validation sets, respectively. The Hosmer-Lemeshow test indicated a strong agreement between the predicted and observed probabilities in the training (χ² = 8.21, p = 0.413) and validation (χ² = 0.64, p = 0.999) sets. In addition, decision-curve analysis suggested that the model had good clinical validity.

Conclusion

This study has constructed and validated original and dynamic nomograms for prolonged ICU stay in patients with COPD using 11 easily collected parameters. These nomograms can provide useful guidance to medical and nursing practitioners in ICUs and help reduce the disease and economic burdens on patients.

Implementation fidelity of a multifactorial in-hospital fall prevention program and its association with unit systems factors: a single center, cross-sectional study

BACKGROUND

Falls are a common, costly global public health burden. In hospitals, multifactorial fall prevention programs have proved effective in reducing falls' incidence; however, translating those programs accurately into daily clinical practice remains challenging. This study's aim was to identify ward-level system factors associated with implementation fidelity to a multifactorial fall prevention program (StuPA) targeting hospitalized adult patients in an acute care setting.

METHODS

This retrospective cross-sectional study used administrative data on 11,827 patients admitted between July and December 2019 to 19 acute care wards at the University Hospital Basel, Switzerland, as well as data on the StuPA implementation evaluation survey conducted in April 2019. Data were analysed using descriptive statistics, Pearson's coefficients and linear regression modelling for variables of interest.

RESULTS

The patient sample had an average age of 68 years and a median length of stay of 8.4 (IQR: 2.1) days. The mean care dependency score was 35.4 points (ePA-AC scale: from 10 points (totally dependent) to 40 points (totally independent)); the mean number of transfers per patient -(e.g., change of room, admission, discharge) was 2.6 (range: 2.4- 2.8). Overall, 336 patients (2.8%) experienced at least one fall, resulting in a rate of 5.1 falls per 1'000 patient days. The median inter-ward StuPA implementation fidelity was 80.6% (range: 63.9-91.7%). We found the mean number of inpatient transfers during hospitalisation and the mean ward-level patient care dependency to be statistically significant predictors of StuPA implementation fidelity.

CONCLUSION

Wards with higher care dependency and patient transfer levels showed higher implementation fidelity to the fall prevention program. Therefore, we assume that patients with the highest fall prevention needs received greater exposure to the program. For the StuPA fall prevention program, our results suggest a need for implementation strategies contextually adapted to the specific characteristics of the target wards and patients.

Factors affecting length of hospital stay in chronic obstructive pulmonary disease patients in a tertiary hospital of Nepal: A retrospective cross-sectional study

Background

Despite the increasing burden of chronic obstructive pulmonary disease in Nepal, studies analyzing the factors associated with inpatient length of hospital stay are lacking.

Methods

This is a retrospective, cross-sectional hospital-based study conducted between July 2020 and July 2021 on patients admitted to the inpatient ward of Pulmonary and Critical Care Medicine of Tribhuvan University Teaching Hospital with a primary diagnosis of acute exacerbation of chronic obstructive pulmonary disease. The sample size of our study was 90. Clinical and demographic factors, blood investigation parameters, and treatment received were analyzed via univariate and multivariate analysis to find the factors associated with length of stay.

Results

The mean age of chronic obstructive pulmonary disease patients was 68.84 ± 10.22 years, with 42.2% of males and 43.3% of current smokers. The length of hospital stay ranged from 2 to 25 days, with an average stay of 6.69 ± 4.02 days. Factors associated with length of stay are the number of comorbidities (p = 0.007), blood eosinophils at admission (p = 0.022), and use of mechanical ventilatory support (p < 0.001).

Conclusions

Proper management of comorbidities and eosinophilic exacerbations as well as careful use of mechanical ventilatory support are required to further reduce the duration of hospital stay in chronic obstructive pulmonary disease patients.

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This study is the first of its kind identifying the factors associated with the length of hospital stay in COPD patients in Nepal.

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COPD is the fifth most common cause of inpatient admission in Nepal and per our study the length of stay was 6.69 days.

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The culprits identified for the increase length of stay were the number of comorbidities, blood eosinophils at admission and use of mechanical ventilator support.

Risk Factors for Length of Hospital Stay in Acute Exacerbation Chronic Obstructive Pulmonary Disease: A Multicenter Cross-Sectional Study

Background/Purpose

Patients and Methods

Results

Conclusion

Characteristics of length of stay and cardiovascular pharmacotherapy advice among chronic obstructive pulmonary disease patients

Chronic obstructive pulmonary disease (COPD) increases the global disease burden due to its diverse adverse health effects on the respiratory and cardiovascular systems. This study aimed to elucidate the potential indicators of length of stay (LOS) and pharmacotherapy advice among COPD patients. Thereafter, hospitalized COPD patients with clinical records and respiratory and cardiovascular pharmacotherapy advice were retrospectively collected from a tertiary hospital between April 2017 and September 2020, and the determinants of LOS and cardiovascular pharmacotherapy advice were explored using regression analyses. Overall, 475 patients with COPD were recruited and stratified according to exacerbation and presence of Cor pulmonale (CP). The extended LOS, increased B-type natriuretic peptides (BNP), and a higher percentage of cardiovascular pharmacotherapy advice were observed in COPD with CP regardless of exacerbation, although the percentage of respiratory prescriptions was comparable. The presence of CP indicated a longer LOS (B = 1.850, p < 0.001) for COPD regardless of exacerbation. Meanwhile, elevated BNP levels indicated cardiovascular pharmacotherapy advise for both COPD in exacerbation (OR = 1.003, p = 0.012) and absence of exacerbation (OR = 1.006, p = 0.015). Moreover, advice for trimetazidine use for COPD in exacerbation (OR = 1.005, p = 0.002) has been suggested. Therefore, CP appears to be an important comorbidity resulting in extended LOS for COPD, which is likely to be advised with cardiovascular pharmacotherapy, which might be guided through BNP monitoring.

The Impact of Comorbidities on Calgary Hospital Utilization in Patients With Chronic Obstructive Pulmonary Disease and Heart Failure

Background

Chronic obstructive pulmonary disease (COPD) and heart failure (HF) are chronic conditions with high acute care utilization. Disease-specific order sets were developed for patients with COPD or HF in Calgary to reduce total days in hospital for this population of patients. However, many patients have comorbidities which may contribute to hospital utilization; thus, disease-specific order sets may not be an optimal solution to reduce overall acute care utilization.

Methods

Inpatient data on Calgary hospitalizations for COPD or HF between April 1, 2017 - March 31, 2019 and associated diagnoses were identified. Outcomes included total days in hospital and length of stay for COPD and HF patients stratified by number of comorbidities.

Results

Total days in hospital increased with the number of comorbidities for both conditions. During the study period, 131 patients with COPD and no comorbidities had a median length of stay of three days (IQR: 3) compared to 3,911 COPD patients with one to five comorbidities with a median length of stay of seven days (IQR: 9). There were 47 patients with HF and no comorbidities with a median length of stay of four days (IQR: 5) compared to 6,273 HF patients with one to five comorbidities with a median length of stay of nine days (IQR: 12). Common comorbidities included hypertension, type 2 diabetes, and acute renal failure. COPD and HF are frequently comorbid. 

Conclusions

Total days in hospital for patients with COPD or HF is positively correlated with the number of comorbidities. COPD or HF patients with between one to five comorbidities (compared to those with no comorbidities, and those with more than five comorbidities) represent the majority of total days in hospital, and the majority of patients. This highlights the importance of focusing on patients with comorbidities in efforts to reduce hospital utilization, and suggests that concurrent management of commonly occurring comorbidities for HF and COPD patients may be necessary to achieve this goal.

Factors Influencing the Length of Hospital Stay Among Patients with Chronic Obstructive Pulmonary Disease (COPD) in Macao Population: A Retrospective Study of Inpatient Health Record

Purpose

This study aims to identify the effects of patient and clinical therapy factors on the length of hospital stay (LOS) for admission due to chronic obstructive pulmonary disease (COPD) in Macao.

Patients and Methods

Health record of patients with COPD admitted to Kiang Wu Hospital from January 2017 to December 2019 was retrospectively analyzed. Demographic information, blood test results, clinical therapies, and LOS were described and analyzed by multivariable regression.

Results

A total of 1116 admissions were included with the average LOS being 12.28 (±9.23) days. Among them, 735 (66.6%) were male with mean age 79.42 (±10.35) years old, 697 were current or previous smokers (62.5%), and 360 (32.2%) had 3 or more comorbidities. During hospitalization, the most common treatments received were oxygen therapy (n=991,88.8%), antibiotics (n=828,74.2%), and systemic steroids (n=596,53.4%); only 120 (10.8%) had pulmonary rehabilitation (PR) and 128 (11.5%) received noninvasive ventilation (NIV). Inhaled medications were used during nearly 95% of hospitalization cases, while 2 and 3 types of inhaled medications were used during 230 (20.6%) and 582 (52.2%) hospitalization cases, respectively. Patient factors including age (B=0.178, 95% CI:0.535–1.072), being female (B=−1.147, 95% CI:-0.138–0.056), being current (B=−0.086, 95% CI:-0.124–0.018) or previous smoker (B=0.072, 95% CI:0.004–0.087), having 1, 2, 3 and over 3 comorbidities (B=0.126, 95% CI:0.034–0.147; B=0.125, 95% CI:0.031–0.144; B=0.116, 95% CI:0.028–0.146, B=0.090, 95% CI:0.021–0.166) and having low hemoglobin level (B=−0.118, 95% CI:-0.629- −0.214) exhibited significant associations with LOS. The use of NIV (B=0.080, 95% CI:0.022–0.138), pulmonary rehabilitation (B=0.269, 95% CI:0.212–0.327), two and three types of inhaled medications (B=0.109, 95% CI:0.003–0.166, B=0.255, 95% CI:0.083–0.237) were significantly associated with longer LOS (P<0.05).

Conclusion

NIV, PR and combined inhaled medications, which are often used for AECOPD, are the main clinical therapies associated with longer LOS in Macao. Smoking cessation, early treatments of comorbidities may be crucial to avoiding AECOPD and reducing LOS and disease burden.

Factors associated with inpatient length of stay among hospitalised patients with chronic obstructive pulmonary disease, China, 2016-2017: a retrospective study

OBJECTIVES

To identify factors associated with length of stay (LOS) in chronic obstructive pulmonary disease (COPD) hospitalised patients, which may help shorten LOS and reduce economic burden accrued over hospital stay.

DESIGN

A retrospective cohort study.

SETTING

This study was performed in a tertiary hospital in China.

PARTICIPANTS

Patients with COPD who were aged ≥40 years and newly admitted between 2016 and 2017.

PRIMARY AND SECONDARY OUTCOME MEASURES

LOS at initial admission was the primary outcome and health expenditures were the secondary outcome. To identify factors associated with LOS, we collected information at index hospitalisation and constructed a conceptual model using directed acyclic graph. Potential factors were classified into five groups: demographic information, disease severity, comorbidities, hospital admission and environmental factors. Negative binomial regression model was fitted for each block of factors and a parsimonious analysis was performed.

RESULTS

In total, we analysed 565 patients with COPD. The mean age was 69±11 years old and 69.4% were men. The median LOS was 10 (interquartile range 8-14) days. LOS was significantly longer in patients with venous thromboembolism (VTE) (16 vs 10 days, p=0.0002) or with osteoporosis (15 vs 10 days, p=0.0228). VTE ((rate ratio) RR 1.38, 95% CI 1.07 to 1.76), hypoxic-hypercarbic encephalopathy (RR 1.53, 95% CI 1.06 to 2.20), respiratory infection (RR 1.12, 95% CI 1.01 to 1.24), osteoporosis (RR 1.45, 95% CI 1.07 to 1.96) and emergence admission (RR 1.08, 95% CI 1.01 to 1.16) were associated with longer LOS. In parsimonious analysis, all these factors remained significant except emergency admission, highlighting the important role of concomitant morbidities in patients' hospital stay. Total hospitalisation cost and patients' out-of-pocket cost increased monotonically with LOS (both p_trend <0.0001).

CONCLUSION

Patients' concomitant morbidities predicted excessive LOS in patients with COPD. Healthcare cost increased over the LOS. Quality improvement initiatives may need to identify patients at high risk for lengthy stay and implement early interventions to reduce COPD economic burden.

CT Imaging and Comorbidities in COPD: Beyond Lung Cancer Screening

Comorbidities significantly contribute to morbidity, mortality, and health-care costs in individuals with COPD. Comorbidity prevalence does not always correlate with lung disease severity, and the elevated risk of certain comorbidities is often independent of shared risk factors such as tobacco burden. Although COPD management guidelines recognize the importance of identifying and treating comorbidities as part of the comprehensive management of COPD patients, little guidance is provided regarding best screening practices. Whereas universal comorbidity screening in COPD patients is likely not cost-effective, targeted early screening and treatment in those at highest risk may have a significant impact on COPD outcomes. Recent studies suggest that certain radiographic features on thoracic imaging may serve as surrogate markers of comorbidity in patients with COPD. This review evaluates these studies in the context of the growing availability of chest CT scans in the lung cancer screening era and discusses how chest CT imaging can be leveraged to identify those COPD patients at highest risk for comorbid disease.

Economic burden of readmission due to postoperative cerebrospinal fluid leak in Chinese patients

Aim: This real-world data study investigated the economic burden and associated factors of readmissions for cerebrospinal fluid leakage (CSFL) post-cranial, transsphenoidal, or spinal index surgeries. Methods: Costs of CSFL readmissions and index hospitalizations during 2014-2018 were collected. Readmission cost was measured as absolute cost and as percentage of index hospitalization cost. Factors associated with readmission cost were explored using generalized linear models. Results: Readmission cost averaged US$2407-6106, 35-94% of index hospitalization cost. Pharmacy costs were the leading contributor. Generalized linear models showed transsphenoidal index surgery and surgical treatment for CSFL were associated with higher readmission costs. Conclusion: CSFL readmissions are a significant economic burden in China. Factors associated with higher readmission cost should be monitored.

Social and clinical predictors associated with prolonged hospital stays for patients with severe exacerbation of chronic obstructive pulmonary disease

OBJECTIVE

To determine whether there are social factors that affect the prolonged hospital stay (PHS) of patients with severe chronic obstructive pulmonary disease exacerbation (COPDE), as well as clinical-demographic factors.

METHODOLOGY

We conducted a prospective cohort study that consecutively included patients who were admitted to a Pneumology department for COPDE. We recorded demographic, clinical (tobacco use, exacerbations and infections, dyspnoea, impact according to CAT questionnaire, pulmonary function, comorbidities, oxygen therapy and noninvasive ventilation) and social (financial status, caregiver availability and overload, dependence for basic and instrumental activities, social risk and use of social services) variables, employing questionnaires and indices such as Barthel, Lawton-Brody, Zarit, Barber and Gijón. We performed a univariate and multivariate analysis using a logistic regression model.

RESULTS

The study included 253 patients, with a mean age of 68.9±9.8years; 77.1% of whom were men. The logistic regression model included active tobacco use, FEV₁ value, CAT score >10, dyspnoea 3-4 on the MMRC, the presence of bacteria in sputum cultures, cardiovascular comorbidity, anaemia, home oxygen therapy, living alone, rural residence, caregiver overload and detecting social-family risks/problems. The variables independently associated with the possibility of PHS were a CAT score >10 (OR, 8.9; P=.04) and detecting a social-family risk/problem (OR, 2.6; P=.04). Active smoking was a predictor of shorter stays (OR, 0.15; P=.002).

CONCLUSIONS

Variables related to the social sphere play a relevant role in hospital stays, as do the impact of the disease and the persistent use of tobacco by patients with severe COPD exacerbation.