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Fabbri LM, Celli BR, Agustí A, Criner GJ, Dransfield MT, Divo M, Krishnan JK, Lahousse L, Montes de Oca M, Salvi SS, Stolz D, Vanfleteren LEGW, Vogelmeier CF. COPD and multimorbidity: recognising and addressing a syndemic occurrence. THE LANCET. RESPIRATORY MEDICINE 2023; 11:1020-1034. [PMID: 37696283 DOI: 10.1016/s2213-2600(23)00261-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 06/21/2023] [Accepted: 06/30/2023] [Indexed: 09/13/2023]
Abstract
Most patients with chronic obstructive pulmonary disease (COPD) have at least one additional, clinically relevant chronic disease. Those with the most severe airflow obstruction will die from respiratory failure, but most patients with COPD die from non-respiratory disorders, particularly cardiovascular diseases and cancer. As many chronic diseases have shared risk factors (eg, ageing, smoking, pollution, inactivity, and poverty), we argue that a shift from the current paradigm in which COPD is considered as a single disease with comorbidities, to one in which COPD is considered as part of a multimorbid state-with co-occurring diseases potentially sharing pathobiological mechanisms-is needed to advance disease prevention, diagnosis, and management. The term syndemics is used to describe the co-occurrence of diseases with shared mechanisms and risk factors, a novel concept that we propose helps to explain the clustering of certain morbidities in patients diagnosed with COPD. A syndemics approach to understanding COPD could have important clinical implications, in which the complex disease presentations in these patients are addressed through proactive diagnosis, assessment of severity, and integrated management of the COPD multimorbid state, with a patient-centred rather than a single-disease approach.
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Affiliation(s)
- Leonardo M Fabbri
- Section of Respiratory Medicine, Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Bartolome R Celli
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Alvar Agustí
- Cátedra Salud Respiratoria, Universitat de Barcelona, Barcelona, Spain; Institut Respiratori, Clínic Barcelona, Barcelona, Spain; Institut d'Investigacions Biomédicas August Pi i Sunyer, Barcelona, Spain; Centro de Investigación Biomédica en Red Enfermedades Respiratorias, Spain
| | - Gerard J Criner
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Mark T Dransfield
- Lung Health Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Miguel Divo
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Jamuna K Krishnan
- Division of Pulmonary and Critical Care, Weill Cornell Medicine, New York, NY, USA
| | - Lies Lahousse
- Department of Bioanalysis, Ghent University, Ghent, Belgium
| | - Maria Montes de Oca
- School of Medicine, Universidad Central de Venezuela, Caracas, Venezuela; Hospital Centro Medico de Caracas, Caracas, Venezuela
| | - Sundeep S Salvi
- Pulmocare Research and Education (PURE) Foundation, Pune, India; School of Health Sciences, Symbiosis International Deemed University, Pune, India
| | - Daiana Stolz
- Clinic of Respiratory Medicine and Pulmonary Cell Research, University Hospital Basel, Basel, Switzerland; Department of Clinical Research, University Hospital Basel, Basel, Switzerland; Clinic of Respiratory Medicine and Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Lowie E G W Vanfleteren
- COPD Center, Department of Respiratory Medicine and Allergology, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Claus F Vogelmeier
- Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Centre Giessen and Marburg, Philipps University of Marburg, Member of the German Centre for Lung Research, Marburg, Germany.
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3
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Grimwood CL, Holland AE, McDonald CF, Mahal A, Hill CJ, Lee AL, Cox NS, Moore R, Nicolson C, O'Halloran P, Lahham A, Gillies R, Burge AT. Comparison of self-report and administrative data sources to capture health care resource use in people with chronic obstructive pulmonary disease following pulmonary rehabilitation. BMC Health Serv Res 2020; 20:1061. [PMID: 33228654 PMCID: PMC7682690 DOI: 10.1186/s12913-020-05920-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 11/12/2020] [Indexed: 02/06/2023] Open
Abstract
Background The optimal method to collect accurate healthcare utilisation data in people with chronic obstructive pulmonary disease (COPD) is not well established. The aim of this study was to determine feasibility and compare self-report and administrative data sources to capture health care resource use in people with COPD for 12 months following pulmonary rehabilitation. Methods This is a secondary analysis of a randomised controlled equivalence trial comparing centre-based and home-based pulmonary rehabilitation. Healthcare utilisation data were collected for 12 months following pulmonary rehabilitation from self-report (monthly telephone questionnaires and diaries) and administrative sources (Medicare Benefits Schedule, medical records). Feasibility was assessed by the proportion of self-reports completed and accuracy was established using month-by-month and per participant comparison of self-reports with administrative data. Results Data were available for 145/163 eligible study participants (89%, mean age 69 (SD 9) years, mean forced expiratory volume in 1 s 51 (SD 19) % predicted; n = 83 male). For 1725 months where data collection was possible, 1160 (67%) telephone questionnaires and 331 (19%) diaries were completed. Accuracy of recall varied according to type of health care encounter and self-report method, being higher for telephone questionnaire report of emergency department presentation (Kappa 0.656, p < 0.001; specificity 99%, sensitivity 59%) and hospital admission (Kappa 0.669, p < 0.001; specificity 97%, sensitivity 68%) and lower for general practitioner (Kappa 0.400, p < 0.001; specificity 62%, sensitivity 78%) and medical specialist appointments (Kappa 0.458, p < 0.001; specificity 88%, sensitivity 58%). A wide variety of non-medical encounters were reported (allied health and nursing) which were not captured in administrative data. Conclusion For self-reported methods of healthcare utilisation in people with COPD following pulmonary rehabilitation, monthly telephone questionnaires were more frequently completed and more accurate than diaries. Compared to administrative records, self-reports of emergency department presentations and inpatient admissions were more accurate than for general practitioner and medical specialist appointments. Trial registration NCT01423227 at clinicaltrials.gov Supplementary Information The online version contains supplementary material available at 10.1186/s12913-020-05920-0.
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Affiliation(s)
- Chantal L Grimwood
- Physiotherapy, The Alfred, PO Box 315, Prahran, VIC, 3181, Australia.,La Trobe University Clinical School, Level 4 The Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Anne E Holland
- Physiotherapy, The Alfred, PO Box 315, Prahran, VIC, 3181, Australia.,La Trobe University Clinical School, Level 4 The Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia.,Department of Allergy, Immunology and Respiratory Medicine, Monash University, Level 6, The Alfred Centre, 99 Commercial Rd, Melbourne, VIC, 3004, Australia.,Institute for Breathing and Sleep, Level 5, Harold Stokes Building, Austin Health, PO Box 5555, Heidelberg, VIC, 3084, Australia
| | - Christine F McDonald
- Institute for Breathing and Sleep, Level 5, Harold Stokes Building, Austin Health, PO Box 5555, Heidelberg, VIC, 3084, Australia.,Department of Respiratory and Sleep Medicine, Austin Health, PO Box 5555, Heidelberg, VIC, 3084, Australia.,Department of Medicine, The University of Melbourne, Parkville, VIC, 3010, Australia
| | - Ajay Mahal
- The Nossal Institute for Global Health, The University of Melbourne, Parkville, VIC, 3010, Australia
| | - Catherine J Hill
- Institute for Breathing and Sleep, Level 5, Harold Stokes Building, Austin Health, PO Box 5555, Heidelberg, VIC, 3084, Australia.,Physiotherapy, Austin Health, PO Box 5555, Heidelberg, VIC, 3084, Australia
| | - Annemarie L Lee
- Physiotherapy, The Alfred, PO Box 315, Prahran, VIC, 3181, Australia.,Institute for Breathing and Sleep, Level 5, Harold Stokes Building, Austin Health, PO Box 5555, Heidelberg, VIC, 3084, Australia.,Physiotherapy, Monash University, Building B, McMahons Rd, Frankston, VIC, 3199, Australia
| | - Narelle S Cox
- La Trobe University Clinical School, Level 4 The Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia.,Department of Allergy, Immunology and Respiratory Medicine, Monash University, Level 6, The Alfred Centre, 99 Commercial Rd, Melbourne, VIC, 3004, Australia.,Institute for Breathing and Sleep, Level 5, Harold Stokes Building, Austin Health, PO Box 5555, Heidelberg, VIC, 3084, Australia
| | - Rosemary Moore
- Institute for Breathing and Sleep, Level 5, Harold Stokes Building, Austin Health, PO Box 5555, Heidelberg, VIC, 3084, Australia
| | - Caroline Nicolson
- Physiotherapy, The Alfred, PO Box 315, Prahran, VIC, 3181, Australia.,La Trobe University Clinical School, Level 4 The Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia.,Department of Allergy, Immunology and Respiratory Medicine, Monash University, Level 6, The Alfred Centre, 99 Commercial Rd, Melbourne, VIC, 3004, Australia
| | - Paul O'Halloran
- Public Health, La Trobe University, Bundoora, VIC, 3086, Australia
| | - Aroub Lahham
- La Trobe University Clinical School, Level 4 The Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia.,Department of Allergy, Immunology and Respiratory Medicine, Monash University, Level 6, The Alfred Centre, 99 Commercial Rd, Melbourne, VIC, 3004, Australia.,Institute for Breathing and Sleep, Level 5, Harold Stokes Building, Austin Health, PO Box 5555, Heidelberg, VIC, 3084, Australia
| | - Rebecca Gillies
- La Trobe University Clinical School, Level 4 The Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Angela T Burge
- Physiotherapy, The Alfred, PO Box 315, Prahran, VIC, 3181, Australia. .,La Trobe University Clinical School, Level 4 The Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia. .,Department of Allergy, Immunology and Respiratory Medicine, Monash University, Level 6, The Alfred Centre, 99 Commercial Rd, Melbourne, VIC, 3004, Australia. .,Institute for Breathing and Sleep, Level 5, Harold Stokes Building, Austin Health, PO Box 5555, Heidelberg, VIC, 3084, Australia.
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4
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Lenferink A, van der Palen J, van der Valk PDLPM, Cafarella P, van Veen A, Quinn S, Groothuis-Oudshoorn CGM, Burt MG, Young M, Frith PA, Effing TW. Exacerbation action plans for patients with COPD and comorbidities: a randomised controlled trial. Eur Respir J 2019; 54:13993003.02134-2018. [PMID: 31413163 DOI: 10.1183/13993003.02134-2018] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 07/22/2019] [Indexed: 11/05/2022]
Abstract
This international randomised controlled trial evaluated whether COPD patients with comorbidities, trained in using patient-tailored multidisease exacerbation action plans, had fewer COPD exacerbation days than usual care (UC).COPD patients (Global Initiative for Chronic Obstructive Lung Disease (GOLD) classification II-IV) with ≥1 comorbidity (ischaemic heart disease, heart failure, diabetes, anxiety, depression) were randomised to a patient-tailored self-management intervention (n=102) or UC (n=99). Daily symptom diaries were completed for 12 months. The primary outcome "COPD exacerbation days per patient per year" was assessed using intention-to-treat analyses.No significant difference was observed in the number of COPD exacerbation days per patient per year (self-management: median 9.6 (interquartile range (IQR) 0.7-31.1); UC: median 15.6 (IQR 3.0-40.3); incidence rate ratio (IRR) 0.87 (95% CI 0.54; 1.39); p=0.546). There was a significantly shorter duration per COPD exacerbation for self-management (self-management: median 8.1 (IQR 4.8-10.1) days; UC: median 9.5 (IQR 7.0-15.1) days; p=0.021), with no between-group differences in the total number of respiratory hospitalisations (IRR 0.76 (95% CI 0.42; 1.35); p=0.348), but a lower probability of ≥1 for respiratory-related hospitalisation compared to UC (relative risk 0.55 (95% CI 0.35; 0.87); p=0.008). No between-group differences were observed in all-cause hospitalisations (IRR 1.07 (95% CI 0.66; 1.72)) or mortality (self-management: n=4 (3.9%); UC: n=7 (7.1%); relative risk 0.55 (95% CI 0.17; 1.84)).Patient-tailored exacerbation action plans for COPD patients with comorbidities did not significantly reduce exacerbation days, but reduced the duration per COPD exacerbation and the risk of having at least one respiratory-related hospitalisation during follow-up, without excess all-cause mortality.
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Affiliation(s)
- Anke Lenferink
- Dept of Pulmonary Medicine, Medisch Spectrum Twente, Enschede, The Netherlands .,Dept of Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, Enschede, The Netherlands.,College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Job van der Palen
- Dept of Pulmonary Medicine, Medisch Spectrum Twente, Enschede, The Netherlands.,Dept of Research Methodology, Measurement, and Data-Analysis, Faculty of Behavioural, Management and Social Sciences, University of Twente, Enschede, The Netherlands
| | | | - Paul Cafarella
- College of Medicine and Public Health, Flinders University, Adelaide, Australia.,Dept of Respiratory Medicine, Southern Adelaide Local Health Network, Adelaide, Australia
| | - Anneke van Veen
- Dept of Pulmonary Medicine, Canisius-Wilhelmina Ziekenhuis, Nijmegen, The Netherlands
| | - Stephen Quinn
- Dept of Statistics, Data Science and Epidemiology, Swinburne University of Technology, Melbourne, Australia
| | - Catharina G M Groothuis-Oudshoorn
- Dept of Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Morton G Burt
- College of Medicine and Public Health, Flinders University, Adelaide, Australia.,Southern Adelaide Diabetes and Endocrine Services, Flinders Medical Centre, Adelaide, Australia
| | - Mary Young
- Dept of Thoracic Medicine, Royal Adelaide Hospital, Adelaide, Australia
| | - Peter A Frith
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Tanja W Effing
- College of Medicine and Public Health, Flinders University, Adelaide, Australia.,Dept of Respiratory Medicine, Southern Adelaide Local Health Network, Adelaide, Australia
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Vela E, Tényi Á, Cano I, Monterde D, Cleries M, Garcia-Altes A, Hernandez C, Escarrabill J, Roca J. Population-based analysis of patients with COPD in Catalonia: a cohort study with implications for clinical management. BMJ Open 2018; 8:e017283. [PMID: 29511004 PMCID: PMC5855237 DOI: 10.1136/bmjopen-2017-017283] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Clinical management of patients with chronic obstructive pulmonary disease (COPD) shows potential for improvement provided that patients' heterogeneities are better understood. The study addresses the impact of comorbidities and its role in health risk assessment. OBJECTIVE To explore the potential of health registry information to enhance clinical risk assessment and stratification. DESIGN Fixed cohort study including all registered patients with COPD in Catalonia (Spain) (7.5 million citizens) at 31 December 2014 with 1-year (2015) follow-up. METHODS A total of 264 830 patients with COPD diagnosis, based on the International Classification of Diseases (Ninth Revision) coding, were assessed. Performance of multiple logistic regression models for the six main dependent variables of the study: mortality, hospitalisations (patients with one or more admissions; all cases and COPD-related), multiple hospitalisations (patients with at least two admissions; all causes and COPD-related) and users with high healthcare costs. Neither clinical nor forced spirometry data were available. RESULTS Multimorbidity, assessed with the adjusted morbidity grouper, was the covariate with the highest impact in the predictive models, which in turn showed high performance measured by the C-statistics: (1) mortality (0.83), (2 and 3) hospitalisations (all causes: 0.77; COPD-related: 0.81), (4 and 5) multiple hospitalisations (all causes: 0.80; COPD-related: 0.87) and (6) users with high healthcare costs (0.76). Fifteen per cent of individuals with highest healthcare costs to year ratio represented 59% of the overall costs of patients with COPD. CONCLUSIONS The results stress the impact of assessing multimorbidity with the adjusted morbidity grouper on considered health indicators, which has implications for enhanced COPD staging and clinical management. TRIAL REGISTRATION NUMBER NCT02956395.
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Affiliation(s)
- Emili Vela
- Area d’Atenció Sanitària, Servei Català de la Salut, Barcelona, Catalonia, Spain
| | - Ákos Tényi
- Hospital Clinic de Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
- Center for Biomedical Network Research in Respiratory Diseases (CIBERES), Madrid, Spain
| | - Isaac Cano
- Hospital Clinic de Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
- Center for Biomedical Network Research in Respiratory Diseases (CIBERES), Madrid, Spain
| | - David Monterde
- Institut Català de la Salut, Serveis Centrals, Catalunya, Spain
| | - Montserrat Cleries
- Area d’Atenció Sanitària, Servei Català de la Salut, Barcelona, Catalonia, Spain
| | - Anna Garcia-Altes
- Agencia de Qualitat i Avaluació Sanitaries de Catalunya (AQuAS), Catalunya, Spain
| | - Carme Hernandez
- Hospital Clinic de Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
- Center for Biomedical Network Research in Respiratory Diseases (CIBERES), Madrid, Spain
| | - Joan Escarrabill
- Hospital Clinic de Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
- Master Plan for Respiratory Diseases (PDMAR), Ministry of Health (Catalonia) REDISSEC, Health Services Research on Chronic Patients Network, Instituto de Salud Carlos III, Barcelona, Spain
| | - Josep Roca
- Hospital Clinic de Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
- Center for Biomedical Network Research in Respiratory Diseases (CIBERES), Madrid, Spain
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