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

Inability to Work Fulltime and the Association with Paid Employment One Year After the Work Disability Assessment: A Longitudinal Register-Based Cohort Study

OBJECTIVES

Disability benefit applicants with residual work capacity are often not able to work fulltime. In Dutch work disability benefit assessments, the inability to work fulltime is an important outcome, indicating the number of hours the applicant can sustain working activities per day. This study aims to gain insight into the association between inability to work fulltime and having paid employment 1 year after the assessment.

METHODS

The study is a longitudinal register-based cohort study of work disability applicants who were granted a partial disability benefit (n = 8300). Multivariable logistic regression analyses were conducted to study the association between inability to work fulltime and having paid employment 1 year after the assessment, separately for working and non-working applicants.

RESULTS

For disability benefit applicants, whether working (31.9%) or not working (68.1%) at the time of the disability assessment, there was generally no association between inability to work fulltime and having paid employment 1 year later. However, for working applicants diagnosed with a musculoskeletal disease or cancer, inability to work fulltime was positively and negatively associated with having paid employment, respectively. For non-working applicants with a respiratory disease or with multimorbidity, inability to work fulltime was negatively associated with paid employment.

CONCLUSIONS

Inability to work fulltime has limited association with paid employment 1 year after the disability benefit assessment, regardless of the working status at the time of assessment. However, within certain disease groups, inability to work fulltime can either increase or decrease the odds of having paid employment after the assessment.

Lung Disease and Social Justice: Chronic Obstructive Pulmonary Disease as a Manifestation of Structural Violence

Lung health, the development of lung disease, and how well a person with lung disease is able to live all depend on a wide range of societal factors. These systemic factors that adversely affect people and cause injustice can be thought of as "structural violence." To make the causal processes relating to chronic obstructive pulmonary disease (COPD) more apparent, and the responsibility to interrupt or alleviate them clearer, we have developed a taxonomy to describe this. It contains five domains: 1) avoidable lung harms (processes impacting lung development, processes that disadvantage lung health in particular groups across the life course), 2) diagnostic delay (healthcare factors; norms and attitudes that mean COPD is not diagnosed in a timely way, denying people with COPD effective treatment), 3) inadequate COPD care (ways in which the provision of care for people with COPD falls short of what is needed to ensure they are able to enjoy the best possible health, considered as healthcare resource allocation and norms and attitudes influencing clinical practice), 4) low status of COPD (ways COPD as a condition and people with COPD are held in less regard and considered less of a priority than other comparable health problems), and 5) lack of support (factors that make living with COPD more difficult than it should be, i.e., socioenvironmental factors and factors that promote social isolation). This model has relevance for policymakers, healthcare professionals, and the public as an educational resource to change clinical practices and priorities and stimulate advocacy and activism with the goal of the elimination of COPD.

Associations of self-reported chronic obstructive pulmonary disease with indicators of economic instability and stress - 16 states, 2017

OBJECTIVES

To examine the association between chronic obstructive pulmonary disease status and indicators of economic instability and stress to better understand the magnitude of these issues in persons with chronic obstructive pulmonary disease.

METHODS

Analyzed 2017 Behavioral Risk Factor Surveillance System data from 16 states that administered the 'Social Determinants of Health' module, which included economic instability and stress measures (N = 101,461). Associations between self-reported doctor-diagnosed chronic obstructive pulmonary disease status and each measure were examined using multinomial logistic models.

RESULTS

Adults with chronic obstructive pulmonary disease were more likely (p < 0.001) than adults without to report not having enough money at month end (21.0% vs. 7.9%) or just enough money (44.9% vs. 37.2%); being unable to pay mortgage, rent, or utility bills (19.2% vs. 8.8%); and that often or sometimes food did not last or could not afford to eat balanced meals (37.9% vs. 20.6%), as well as stress all or most of the time (27.3% vs. 11.6%). Associations were attenuated although remained significant after adjustments for sociodemographic and health characteristics.

DISCUSSION

Financial, housing, and food insecurity and frequent stress were more prevalent in adults with chronic obstructive pulmonary disease than without. Findings highlight the importance of including strategies to address challenges related to economic instability and stress in chronic obstructive pulmonary disease management programs.

Effect of telemonitoring on quality of life for patients with chronic obstructive pulmonary disease-A randomized controlled trial

INTRODUCTION

Patients with chronic obstructive pulmonary disease (COPD) often experience severe physical limitations and psychological distress, which can lead to a deterioration in quality of life (QoL). Telemonitoring (TM) may improve QoL and reduce the number of hospitalizations and readmissions, but results from previous studies have been conflicting. The aim of this study was to assess the effect of TM on QoL in patients with moderate to severe COPD recruited during hospitalization for acute exacerbation (AECOPD).

METHODS

We conducted a randomized controlled trial at Silkeborg and Viborg Regional Hospitals in Denmark. Participants were recruited during hospitalization for AECOPD and randomized to a six-month telemonitoring service in addition to standard COPD care or standard COPD care alone. Patients were followed for 24 months. QoL was measured by the Hospital Anxiety and Depression Scale (HADS), and St Georges Respiratory Questionnaire (SGRQ) at 3-, 6-, 12-, and 24-months follow-up. The main outcome was QoL at 6 months.

RESULTS

In total, 101 patients were randomized to the TM intervention and 97 to standard care. The between-group difference in SGRQ at 6 months was -2.0 (-8.5; 4.5), in HADS-Anxiety -0.3 (-2.0; 1.4) and in HADS-depression 0.2 (-1.0; 1.4) corresponding to no significant difference in health-related QoL for patients receiving TM compared to standard care. No difference was seen at 12-24 months follow-up either.

DISCUSSION

TM in addition to standard care did not improve QoL in patients with moderate to severe COPD. Other means of improving management and QoL in severe COPD are urgently needed.

Photovoice exploration of physical activity norms and values among rural and remote pulmonary rehabilitation participants in British Columbia, Canada

PURPOSE

Individuals with chronic obstructive pulmonary disease (COPD) engage in less physical activity compared to the general population, which can lead to worsened symptoms. In pulmonary rehabilitation (PR) programs, participants learn strategies to complete activities more easily. For such strategies to be effective, however, PR clinicians must understand their clients' activity values and practices within their geocultural contexts. In this qualitative study, our aim was to explore physical activity norms and values among people with COPD living in remote and rural locations, using Photovoice methodology.

MATERIALS AND METHODS

We recruited 12 participants from rural PR sites in British Columbia, Canada. During two distinct seasons (winter and summer), participants photographed meaningful activities then completed semi-structured interviews. We analyzed transcripts using a three-step hermeneutic method, which revealed three themes.

RESULTS

Participants discussed feeling conflicted regarding their COPD symptoms and physical activity, as difficulties in activity engagement cause stress, but remaining active also fosters a sense of purpose and well-being. Meanwhile, participants' activities are inextricably linked to their rural, remote, and seasonal environment.

CONCLUSIONS

Our study provides insight into how people with COPD resiliently engage in activities in a rural environment with distinct weather variations. Findings highlight the importance of considering individual factors when recommending activities in PR programs.Implications for rehabilitationAlthough people with chronic lung disease often encounter difficulty and stress in completing their daily activities, they both recognize the importance of and derive great personal meaning from remaining active.The unique social, geographical, physical, and climatic environments of rural and remote dwelling people with chronic lung disease can both enable and challenge their activity engagement.Pulmonary rehabilitation (PR) programs and clinicians must situate their activity recommendations within the geographic contexts of their clients - which can vary across the seasons.Support for participants' mental health is a vital aspect of PR.

Might Dog Walking Reduce the Impact of COPD on Patients' Life?

Low levels of physical activity (PA) lead to a worsening of physical condition and contributes to multimorbidity in Chronic Obstructive Respiratory Disease (COPD). Unsupervised PA related to dog ownership may contribute to reducing sedentary behavior. We aimed to investigate the relationship between dog walking, patient-reported outcomes (PROs) and exacerbations in COPD. A pre-defined sample of 200 COPD patients (dog owners and non-dog owners) with symptomatic COPD was sourced from a database representative of the Italian population. A computer-assisted personal interview was used to assess health status impairment (CAT), fatigue (FACIT), health-related quality of life (HRQoL) (EQ-5D), and PA frequency. In the whole sample, PA was associated with better CAT, EQ-5D, VAS, FACIT scores and reduced number of exacerbation (p < 0.001). Under the same CAT scores, dog-walking duration was associated with a better HRQoL (EQ5D, p = 0.015) and less fatigue (FACIT, p = 0.017). In an adjusted regression model, walking dogs >30 min was associated with lower fatigue (FACIT) than having no dogs and walking dogs <15 min (p = 0.026 and p = 0.009, respectively). Motivation related to dog walking could modify patients’ tendency to focus on symptoms during PA and, therefore, to perceive the fatigue. Dog walking may be effective for increasing and maintaining regular PA, reducing the subjective impact of COPD.

Disability Retirement After First Admission with Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Danish Nationwide Registry Cohort Study Using a Retrospective Follow-Up Design

Introduction

Many chronic obstructive pulmonary disease (COPD) patients below retirement age are outside the workforce. The existing knowledge about association between acute exacerbation of COPD (AECOPD) and disability retirement is limited.

Aim

The aim of this study is to explore disability retirement in COPD patients 3 years following first-ever AECOPD.

Methods

This retrospective registry-based follow-up cohort study design is based on nationwide Danish registry data. Patients admitted to the hospital for the first time between 1999 and 2017 with AECOPD and age between 35 and 59 years, active in the workforce, were included in the study. Socio-demographics, comorbidities and inhaled medication use were explored. COPD patients’ hazard ratio of disability retirement during 3-year follow-up was calculated. Cox regression was used to examine the effects of covariates on disability retirement.

Results

A total of 4032 patients were included in the study. During follow-up, 17.2% (692/4032) experienced disability retirement from the workforce. Factors associated with disability retirement were expressed as hazard ratio (95% confidence intervals): Higher age (ref. age 46–50: Age 51–55, 1.42, (1.12–1.81); age 56–59, 1.37 (1.08–1.74)); living alone (1.34 (1.14–1.56)); number of comorbidities for 1, 2, and 3 comorbidities (1.36 (1.14–1.62), 1.57 (1.19–2.07), 1.77 (1.20–2.60)); emphysema (2.01 (1.44–2.79)); depression (1.60 (1.12–2.28)); cardiac comorbidity (1.38 (1.07–1.78)); triple inhalation therapy (2.76 (2.20–3.47)); ICS + LAMA or ICS + LABA treatment (1.82 (1.48–2.23)); and ICS treatment (1.49 (1.17–1.90)). Higher educational level was associated with a significantly reduced risk of disability retirement, medium, short higher and long higher educational level, relative to low education level (0.78 (0.67–0.91), 0.63 (0.48–0.83) and 0.27 (0.12–0.60)).

Conclusion

Patients vulnerable to disability retirement are patients with markers of severe COPD, comorbidities, and social vulnerability.

Suboptimal Peak Inspiratory Flow and Critical Inhalation Errors are Associated with Higher COPD-Related Healthcare Costs

Purpose

To assess the relationship between suboptimal Peak Inspiratory Flow (sPIF), inhalation technique errors, and non-adherence, with Healthcare Resource Utilisation (HCRU) in Chronic Obstructive Pulmonary Disease (COPD) patients receiving maintenance therapy via a Dry Powder Inhaler (DPI).

Patients and methods

The cross-sectional, multi-country PIFotal study included 1434 COPD patients (≥40 years) using a DPI for maintenance therapy. PIF was measured with the In-Check DIAL G16, and sPIF was defined as a typical PIF lower than required for the device. Inhalation technique was assessed by standardised evaluation of video recordings and grouped into 10 steps. Patients completed the “Test of Adherence to Inhalers” questionnaire. HCRU was operationalised as COPD-related costs for primary healthcare, secondary healthcare, medication, and total COPD-related costs in a 1-year period.

Results

Participants with sPIF had higher medication costs compared with those with optimal PIF (cost ratio [CR]: 1.07, 95% CI [1.01, 1.14]). Multiple inhalation technique errors were associated with increased HCRU. Specifically, “insufficient inspiratory effort” with higher secondary healthcare costs (CR: 2.20, 95% CI [1.37, 3.54]) and higher total COPD-related costs (CR: 1.16, 95% CI 1.03–1.31). “no breath-hold following the inhalation manoeuvre (<6 s)” with higher medication costs (CR: 1.08, 95% CI [1.02, 1.15]) and total COPD-related costs (CR 1.17, 95% CI [1.07, 1.28]), and “not breathing out calmly after inhalation” with higher medication costs (CR: 1.19, 95% CI [1.04, 1.37]). Non-adherence was not significantly associated with HCRU.

Conclusion

sPIF and inhalation technique errors were associated with higher COPD-related healthcare utilisation and costs in COPD patients on DPI maintenance therapy.

Remote patient monitoring in the management of chronic obstructive pulmonary disease

Remote patient monitoring allows monitoring high-risk patients through implementation of an expanding number of technologies in coordination with a healthcare team to augment care, with the potential to provide early detection of exacerbation, prompt access to therapy and clinical services, and ultimately improved patient outcomes and decreased healthcare utilization.In this review, we describe the application of remote patient monitoring in chronic obstructive pulmonary disease including the potential benefits and possible barriers to implementation both for the individual and the healthcare system.

Occupational COPD-The most under-recognized occupational lung disease?

Chronic obstructive pulmonary disease (COPD) is caused by exposure to noxious particles and gases. Smoking is the main risk factor, but other factors are also associated with COPD. Occupational exposure to vapours, gases, dusts and fumes contributes to the development and progression of COPD, accounting for a population attributable fraction of 14%. Workplace pollutants, in particular inorganic dust, can initiate airway damage and inflammation, which are the hallmarks of COPD pathogenesis. Occupational COPD is still underdiagnosed, mainly due to the challenges of assessing the occupational component of the disease in clinical settings, especially if other risk factors are present. There is a need for specific education and training for clinicians, and research with a focus on evaluating the role of occupational exposure in causing COPD. Early diagnosis and identification of occupational causes is very important to prevent further decline in lung function and to reduce the health and socio-economic burden of COPD. Establishing details of the occupational history by general practitioners or respiratory physicians could help to define the occupational burden of COPD for individual patients, providing the first useful interventions (smoking cessation, best therapeutic management, etc.). Once patients are diagnosed with occupational COPD, there is a wide international variation in access to specialist occupational medicine and public health services, along with limitations in workplace and income support. Therefore, a strong collaboration between primary care physicians, respiratory physicians and occupational medicine specialists is desirable to help manage COPD patients' health and social issues.

Employment Status, Readmission and Mortality After Acute Exacerbation of COPD

Introduction

The understanding of whether and to what extent employment status affects readmission and mortality is limited in patients with COPD.

Aim

To explore how employment status affects readmission and mortality after first admission to the hospital with acute exacerbation of COPD (AECOPD).

Methods

This study used Danish national registry-based data. All patients admitted for the first time to the hospital between 1999 and 2014 with a diagnosis of AECOPD, age 35–59, without a previous asthma diagnosis were included in the study. Employment status effect on 30-, 90-, and 365-day readmission and mortality was examined using logistic regression, adjusting for relevant confounders.

Results

A total of 11,850 COPD patients were included in the study of which 3563 (30%) were working, 1368 (12%) unemployed, 840 (7%) on sick leave, and 6079 (51%) receiving early retirement. Patients receiving early retirement had, compared to patients working, an adjusted increased likelihood of readmission at 30, 90, and 365 days (odds ratio (OR) 1.26 (CI^95% (1.06–1.49)), 1.33 (CI^95% (1.16–1.53)), and 1.48 (CI^95% (1.33–1.66)), respectively). An increased likelihood was also seen in unemployed at 365 days follow-up (OR 1.44 (CI^95% (1.22–1.68))). Early retirement was associated with an increased mortality at 30, 90, and 365 days (OR 1.39 (CI^95% (1.07–1.80)) 1.37 (CI^95% (1.09–1.79)) and 1.48 (CI^95% (1.25–1.75)), respectively). An increased likelihood was also seen in patients receiving sick leave (OR 1.57 (CI^95% (1.21–2.04))).

Conclusion

Patients with COPD who are not working at the time of first admission have a higher likelihood of readmission and mortality.

Chronic Obstructive Pulmonary Disease Patients' Acceptance in E-Health Clinical Trials

INTRODUCTION

Telehealth (TH) interventions with Chronic Obstructive Pulmonary Disease (COPD) management were introduced in the literature more than 20 years ago with different labeling, but there was no summary for the overall acceptance and dropout rates as well as associated variables.

OBJECTIVE

This review aims to summarize the acceptance and dropout rates used in TH interventions and identify to what extent clinical settings, sociodemographic factors, and intervention factors might impact the overall acceptance and completion rates of TH interventions.

METHODS

We conducted a systematic search up to April 2021 on CINAHL, PubMed, MEDLINE (Ovid), Cochrane, Web of Sciences, and Embase to retrieve randomized and non-randomized control trials that provide TH interventions alone or accompanied with other interventions to individuals with COPD.

RESULTS

Twenty-seven studies met the inclusion criteria. Overall, the unweighted average of acceptance and dropout rates for all included studies were 80% and 19%, respectively. A meta-analysis on the pooled difference between the acceptance rates and dropout rates (weighted by the sample size) revealed a significant difference in acceptance and dropout rates among all TH interventions 51% (95% CI 49% to 52; p < 0.001) and 63% (95% CI 60% to 67; p < 0.001), respectively. Analysis revealed that acceptance and dropout rates can be impacted by trial-related, sociodemographic, and intervention-related variables. The most common reasons for dropouts were technical difficulties (33%), followed by complicated system (31%).

CONCLUSIONS

Current TH COPD interventions have a pooled acceptance rate of 51%, but this is accompanied by a high dropout rate of 63%. Acceptance and dropout levels in TH clinical trials can be affected by sociodemographic and intervention-related factors. This knowledge enlightens designs for well-accepted future TH clinical trials. PROSPERO registration number CRD4201707854.

Benefit/Risk Profile of Single-Inhaler Triple Therapy in COPD

Chronic obstructive pulmonary disease (COPD) is associated with major healthcare and socioeconomic burdens. International consortia recommend a personalized approach to treatment and management that aims to reduce both symptom burden and the risk of exacerbations. Recent clinical trials have investigated single-inhaler triple therapy (SITT) with a long-acting muscarinic antagonist (LAMA), long-acting β2-agonist (LABA), and inhaled corticosteroid (ICS) for patients with symptomatic COPD. Here, we review evidence from randomized controlled trials showing the benefits of SITT and weigh these against the reported risk of pneumonia with ICS use. We highlight the challenges associated with cross-trial comparisons of benefit/risk, discuss blood eosinophils as a marker of ICS responsiveness, and summarize current treatment recommendations and the position of SITT in the management of COPD, including potential advantages in terms of improving patient adherence. Evidence from trials of SITT versus dual therapies in symptomatic patients with moderate to very severe airflow limitation and increased risk of exacerbations shows benefits in lung function and patient-reported outcomes. Moreover, the key benefits reported with SITT are significant reductions in exacerbations and hospitalizations, with data also suggesting reduced all-cause mortality. These benefits outweigh the ICS-class effect of higher incidence of study-reported pneumonia compared with LAMA/LABA. Important differences in trial design, baseline population characteristics, such as exacerbation history, and assessment of outcomes, have significant implications for interpreting data from cross-trial comparisons. Current understanding interprets the blood eosinophil count as a continuum that can help predict response to ICS and has utility alongside other clinical factors to aid treatment decision-making. We conclude that treatment decisions in COPD should be guided by an approach that considers benefit versus risk, with early optimization of treatment essential for maximizing long-term benefits and patient outcomes.

Work absence in patients with asthma and/or COPD: a population-based study

Chronic obstructive pulmonary disease (COPD) and asthma impact on work productivity, but their population-based burden and clinical predictors are understudied. In this observational, real-life study, work absence of 14,383 asthma and/or COPD patients present in the MAJORICA cohort (Spain) was compared with the general population. Using multivariable regression, we studied the association of work absence with demographic and clinical characteristics. Patients with asthma and/or COPD had more work absence than the general population (15.2% vs 8.9%, p < 0.0001). Patients with asthma had more often periods of work absence compared to patients with COPD (16.0% vs 12.8%, p < 0.0001). The number of days absent were, however, less in asthma than in COPD (median: 15 days [IQR: 5–51] vs 39 days [IQR: 13–134], p < 0.001). Patients with asthma–COPD overlap were in between (14.5% with absence; median: 27 days [IQR: 10–82]). Comorbid anxiety, allergic rhinitis, and sleep apnoea were independently associated with more work absence.

InforMing the PAthway of COPD Treatment (IMPACT Trial) Single-Inhaler Triple Therapy (Fluticasone Furoate/Umeclidinium/Vilanterol) Versus Fluticasone Furoate/Vilanterol and Umeclidinium/Vilanterol in Patients With COPD: Analysis of the Western Europe and North America Regions

BACKGROUND

The InforMing the Pathway of COPD Treatment (IMPACT) trial demonstrated lower moderate/severe exacerbation rates with fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI) versus FF/VI or UMEC/VI in patients with chronic obstructive pulmonary disease (COPD) and a history of exacerbations. Since IMPACT was a global study, post-hoc analyses were conducted by geographic region to investigate potential differences in overall findings.

METHODS

IMPACT was a 52-week, randomized, double-blind trial. Patients with symptomatic COPD and ≥1 moderate/severe exacerbation in the prior year were randomized 2:2:1 to once-daily FF/UMEC/VI 100/62.5/25µg, FF/VI 100/25µg, or UMEC/VI 62.5/25µg. Endpoints assessed in the overall, Western Europe and North America populations included on-treatment moderate/severe exacerbation (rates and time-to-first), trough forced expiratory volume in 1 second and St George's Respiratory Questionnaire (SGRQ) total score. Safety was assessed.

RESULTS

Overall, 10,355 patients were enrolled, 3164 from Western Europe, 2639 from North America. FF/UMEC/VI significantly reduced on-treatment moderate/severe exacerbation rates versus FF/VI and UMEC/VI in Western Europe (rate ratios 0.82 [95%CI 0.74-0.91], P<.001 and 0.76 [0.67-0.87], P<.001) and in North America (0.87 [0.77-0.97], P=.014 and 0.69 [0.60-0.80], P<.001). FF/UMEC/VI reduced time-to-first moderate/severe exacerbation and improved lung function versus FF/VI and UMEC/VI in both regions, and improved SGRQ total score in Western Europe, but not North America. Safety profiles were generally similar between treatment groups/regions; the inhaled corticosteroid class effect of increased pneumonia incidence was seen in North America but not Western Europe.

CONCLUSION

Consistent with intent-to-treat results, FF/UMEC/VI reduced moderate/severe exacerbation rate and risk and improved lung function in Western Europe and North America; however, between-regions differences were seen for SGRQ total score and pneumonia incidence.

CLINICAL TRIAL REGISTRATION

NCT02164513.

Chronic Obstructive Pulmonary Disease and Employment Among Massachusetts Adults

Occupational exposure may cause or exacerbate chronic obstructive pulmonary disease (COPD), but employment may also enhance health and well-being for people with the disorder. We used self-reported data from the 2011-2017 Massachusetts Behavioral Risk Factor Surveillance System to examine COPD and employment among adults aged 40 to 70. Thirty-nine percent of adults with COPD were employed. Workers with COPD were more likely than those without COPD to report indicators of poor physical and mental health, and distribution by occupation differed between the 2 groups. Findings suggest workplace interventions may be needed to prevent respiratory exposures and enhance support for employees with COPD.

Daily Impact of COPD in Younger and Older Adults: Global Online Survey Results from over 1,300 Patients

The daily impact of chronic obstructive pulmonary disease (COPD) on younger patients is often underappreciated. To assess this, we investigated the disease burden experienced by younger and older patients. A panel of questions was developed in conjunction with the European Federation of Allergy and Airways Diseases Patients' Associations and Boehringer Ingelheim. The online survey was conducted by Instar Research. Data were collected from eight countries in Europe, plus China, Japan and the United States. All patients were receiving COPD maintenance therapy. Patients were stratified by age (45-54, 55-64, ≥65 years). Data were analyzed from 1,375 patients from Europe (925), China (150), Japan (100) and the US (200); 365 were aged 45-54, 440 aged 55-64, and 570 aged ≥65 years. Mean age was 61.8 years; 771 (56%) were male. A significantly higher proportion of patients aged 45-54 years reported "poor" or "very poor" wellbeing (35% vs. 28%; p < 0.05) and "high impact" on 8 of the 11 daily activities and requirements for adjusting activities assessed (all p < 0.05), compared with patients aged ≥65 years. Significantly more patients aged 45-54 versus ≥65 years associated their COPD with feeling "anxious", "stressed", "sad", or "overwhelmed" (all p < 0.05). Younger patients with COPD reported a higher impact on their daily activities, wellbeing and requirement for adjusting their activities due to their symptoms than older patients. Our findings highlight the importance of optimizing treatment for younger patients with COPD and suggest that clinicians should not overlook the burden of disease in these patients.

Incorporating the Environmental Impact into a Budget Impact Analysis: The Example of Adopting RESPIMAT® Re-usable Inhaler

BACKGROUND

RESPIMAT® re-usable enables patients to re-use the inhaler and its availability therefore reduces the number of inhalers and associated wastage.

OBJECTIVE

The objective of this study was to perform an economic evaluation that incorporates the ecological impact of adopting RESPIMAT re-usable into the healthcare system in Germany.

METHODS

Inhaler costs and environmental impact over 5 years in Germany in a scenario with RESPIMAT re-usable compared to a scenario without RESPIMAT re-usable were estimated using a budget impact model. The carbon emissions were derived for each treatment pattern considering the whole life cycle (cradle-to-grave) of the inhaler product. The cost of carbon emissions was estimated using a societal cost per ton of carbon emission.

RESULTS

By introducing RESPIMAT re-usable in Germany, it was estimated that by 2023, the number of inhalers used would have decreased by 5,748,750 compared to a scenario without RESPIMAT re-usable. In addition, this measure would reduce the environmental burden of inhaler use while at the same time reducing medical cost of inhalers.

CONCLUSIONS

Adopting RESPIMAT® re-usable to the national healthcare services may be a cost-saving option, which has the additional benefit of reducing the societal cost of carbon emissions.

Recommendations for Developing Support Tools With People Suffering From Chronic Obstructive Pulmonary Disease: Co-Design and Pilot Testing of a Mobile Health Prototype

BACKGROUND

Gaps exist between developers, commissioners, and end users in terms of the perceived desirability of different features and functionalities of mobile apps.

OBJECTIVE

The objective of this study was to co-design a prototype mobile app for people with chronic obstructive pulmonary disease (COPD). We present lessons learned and recommendations from working on a large project with various stakeholders to develop a mobile app for patients with COPD.

METHODS

We adopted a user-centered, participatory approach to app development. Following a series of focus groups and interviews to capture requirements, we developed a prototype app designed to enable daily symptom recording (experience sampling). The prototype was tested in a usability study applying the think aloud protocol with people with COPD. It was then released via the Android app store, and experience sampling data and event data were captured to gather further usability data.

RESULTS

A total of 5 people with COPD participated in the pilot study. Identified themes include familiarity with technology, appropriate levels for feeding back information, and usability issues such as manual dexterity. Moreover, 37 participants used the app over a 4-month period (median age 47 years). The symptoms most correlated to perceived well-being were tiredness (r=0.61; P<.001) and breathlessness (r=0.59; P<.001).

CONCLUSIONS

Design implications for COPD apps include the need for clearly labeled features (rather than relying on colors or symbols that require experience using smartphones), providing weather information, and using the same terminology as health care professionals (rather than simply lay terms). Target users, researchers, and developers should be involved at every stage of app development, using an iterative approach to build a prototype app, which should then be tested in controlled settings as well as in the wild (ie, when deployed and used in real-world settings) over longer periods.

Goals of COPD treatment: Focus on symptoms and exacerbations

Chronic obstructive pulmonary disease (COPD) is currently a leading cause of death worldwide, and its burden is expected to rise in the coming years. Common COPD symptoms include dyspnea, cough and/or sputum production. Some patients may experience acute worsening of symptoms (known as an exacerbation), and therefore require additional therapy. Exacerbations are mainly triggered by respiratory infections and environmental factors. Healthcare professionals face many challenges in COPD management, including the heterogeneity of the disease and under-reporting of symptoms. The authors review these challenges and provide recommendations for the best methods to assess COPD. The goals of COPD treatment include recognising the impact that both symptoms and exacerbations have on patients' lives when considering optimal patient-focused management. The review discusses the need for COPD management strategies to include both pharmacologic and non-pharmacologic approaches and provides recommendations for monitoring treatment outcomes and adjusting management strategies accordingly. Novel treatment strategies including precision medicine and point-of-care testing are also discussed.

Does lung function predict the risk of disability pension? An 11-year register-based follow-up study

Background

Spirometry is widely used in medical surveillance in occupational health and as a diagnostic test for obstructive and restrictive lung disease. We evaluated the effect of spirometry parameters on the risk of all-cause disability pension in a follow-up study of an occupationally active general population-based cohort.

Methods

We measured the pulmonary function of 3386 currently working participants of the Health 2000 Survey in the clinical phase at baseline using spirometry. We obtained the retirement events of the cohort from the nationwide register for 2000–2011. Cox proportional hazards models were used to determine disability pensions.

Results

At baseline, we identified 111 (3.3%) participants with obstructive spirometry, 95 (2.8%) with restrictive spirometry, and 3180 controls without restriction or obstruction. The age, sex, educational level, body-mass index, co-morbidities (1 or ≥ 2), and the smoking-adjusted hazard ratio of disability pension was 1.07 (95% confidence interval, CI 0.64–1.78) for those with obstructive spirometry, and 1.44 (95% CI 0.89–2.32) for those with restrictive spirometry. As continuous variables, and divided into quartiles, the risk of the lowest quartile of forced ventilation capacity (FVC)% of predicted was 1.49 (95%CI 1.10–2.01) and forced expiratory volume in one second (FEV₁)% of predicted 1.66 (95%CI: 1.23–2.24) in comparison to the highest quartile in the adjusted models.

Conclusions

Obstructive or restrictive spirometry did not predict disability pension when dichotomized classified variables (normal compared to abnormal) were used. As continuous variables and when divided into quartiles, lower lung volumes showed an increase in the risk of disability pension. Physicians should take this into account when they use spirometry as a prognostic factor of work disability.

The socioeconomic burden of chronic lung disease in low-resource settings across the globe - an observational FRESH AIR study

Background

Low-resource settings are disproportionally burdened by chronic lung disease due to early childhood disadvantages and indoor/outdoor air pollution. However, data on the socioeconomic impact of respiratory diseases in these settings are largely lacking. Therefore, we aimed to estimate the chronic lung disease-related socioeconomic burden in diverse low-resource settings across the globe. To inform governmental and health policy, we focused on work productivity and activity impairment and its modifiable clinical and environmental risk factors.

Methods

We performed a cross-sectional, observational FRESH AIR study in Uganda, Vietnam, Kyrgyzstan, and Greece. We assessed the chronic lung disease-related socioeconomic burden using validated questionnaires among spirometry-diagnosed COPD and/or asthma patients (total N = 1040). Predictors for a higher burden were studied using multivariable linear regression models including demographics (e.g. age, gender), health parameters (breathlessness, comorbidities), and risk factors for chronic lung disease (smoking, solid fuel use). We applied identical models per country, which we subsequently meta-analyzed.

Results

Employed patients reported a median [IQR] overall work impairment due to chronic lung disease of 30% [1.8–51.7] and decreased productivity (presenteeism) of 20.0% [0.0–40.0]. Remarkably, work time missed (absenteeism) was 0.0% [0.0–16.7]. The total population reported 40.0% [20.0–60.0] impairment in daily activities. Breathlessness severity (MRC-scale) (B = 8.92, 95%CI = 7.47–10.36), smoking (B = 5.97, 95%CI = 1.73–10.22), and solid fuel use (B = 3.94, 95%CI = 0.56–7.31) were potentially modifiable risk factors for impairment.

Conclusions

In low-resource settings, chronic lung disease-related absenteeism is relatively low compared to the substantial presenteeism and activity impairment. Possibly, given the lack of social security systems, relatively few people take days off work at the expense of decreased productivity. Breathlessness (MRC-score), smoking, and solid fuel use are potentially modifiable predictors for higher impairment. Results warrant increased awareness, preventive actions and clinical management of lung diseases in low-resource settings from health policymakers and healthcare workers.

A Budget Impact Model to Estimate the Environmental Impact of Adopting RESPIMAT® Re-usable in the Nordics and Benelux

Introduction

The healthcare sector contributes 5–8% of the global greenhouse gas emissions. Global and regional organizations and governments have started to design and implement measures to reduce global greenhouse gas emissions in the healthcare sector, e.g. by green public procurement policies and inclusion of ecological considerations in the decision-making process for purchasing and funding of healthcare technologies. The objective of this study was to perform budget impact analysis of adopting RESPIMAT re-usable in the Nordics and Benelux that considered both the traditional healthcare costs as well as the environmental impact.

Methods

Inhaler costs and environmental impact over 5 years in the Nordics and Benelux in a scenario with RESPIMAT re-usable compared to a scenario without RESPIMAT re-usable were estimated using an budget impact model. RESPIMAT re-usable enables patients to re-use the inhaler device and its availability therefore reduces the number of inhalers and associated wastage. The carbon emissions were derived for each treatment pattern considering the whole life cycle (cradle-to-grave) of the inhaler product. The cost of carbon emissions was estimated using a societal cost per ton of carbon emission.

Results

Progressively introducing RESPIMAT re-usable in the Nordics and Benelux was estimated to decrease the number of inhalers used by 2023 by 7,466,621 compared to a scenario without RESPIMAT re-usable, which would result in a reduction of the environmental burden of inhaler use of 4717 tCO₂e and a decrease in societal cost of €205,888.

Conclusions

Adopting RESPIMAT re-usable would lead to a substantial reduction in CO₂ emissions, leading to savings from a societal perspective.

Funding

Boehringer Ingelheim.

Electronic supplementary material

The online version of this article (10.1007/s12325-019-01114-1) contains supplementary material, which is available to authorized users.

Trends in morbidity and mortality from COPD in Brazil, 2000 to 2016

Objective:

To examine the trends in overall COPD mortality, as well as trends in in-hospital morbidity and mortality due to COPD, in Brazil, and to validate predictive models.

Methods:

This was a population-based study with a time-series analysis of cause-specific morbidity and mortality data for individuals ≥ 40 years of age, obtained from national health information systems for the 2000-2016 period. Morbidity and mortality rates, stratified by gender and age group, were calculated for the same period. We used regression analyses to examine the temporal trends and double exponential smoothing in our analysis of the predictive models for 2017.

Results:

Over the study period, COPD mortality rates trended downward in Brazil. For both genders, there was a downward trend in the southern, southeastern, and central-western regions. In-hospital morbidity rates declined in all regions, more so in the south and southeast. There were significant changes in the number of hospitalizations, length of hospital stay, and hospital expenses. The predictive models for 2017 showed error rates below 9% and were therefore validated.

Conclusions:

In Brazil, COPD age-adjusted mortality rates have declined in regions with higher socioeconomic indices, where there has been an even sharper decrease in all in-hospital morbidity and mortality variables. In addition to factors such as better treatment adherence and reduced smoking rates, socioeconomic factors appear to be involved in controlling COPD morbidity and mortality. The predictive models estimated here might also facilitate decision making and the planning of health policies aimed at treating COPD.

Direct and indirect costs of COPD progression and its comorbidities in a structured disease management program: results from the LQ-DMP study

Background

Evidence on the economic impact of chronic obstructive pulmonary disease (COPD) for third-party payers and society based on large real world datasets are still scarce. Therefore, the aim of this study was to estimate the economic impact of COPD severity and its comorbidities, stratified by GOLD grade, on direct and indirect costs for an unselected population enrolled in the structured German Disease Management Program (DMP) for COPD.

Methods

All individuals enrolled in the DMP COPD were included in the analysis. Patients were only excluded if they were not insured or not enrolled in the DMP COPD the complete year before the last DMP documentation (at physician visit), had a missing forced expiratory volume in 1 s (FEV₁) measurement or other missing values in covariates. The final dataset included 39,307 patients in GOLD grade 1 to 4. We used multiple generalized linear models to analyze the association of COPD severity with direct and indirect costs, while adjusting for sex, age, income, smoking status, body mass index, and comorbidities.

Results

More severe COPD was significantly associated with higher healthcare utilization, work absence, and premature retirement. Adjusted annual costs for GOLD grade 1 to 4 amounted to €3809 [€3691–€3935], €4284 [€4176–€4394], €5548 [€5328–€5774], and €8309 [€7583-9065] for direct costs, and €11,784 [€11,257–€12,318], €12,985 [€12,531-13,443], €15,805 [€15,034–€16,584], and €19,402 [€17,853–€21,017] for indirect costs. Comorbidities had significant additional effects on direct and indirect costs with factors ranging from 1.19 (arthritis) to 1.51 (myocardial infarction) in direct and from 1.16 (myocardial infarction) to 1.27 (cancer) in indirect costs.

Conclusion

The findings indicate that more severe GOLD grades in an unselected COPD population enrolled in a structured DMP are associated with tremendous additional direct and indirect costs, with comorbidities significantly increase costs. In direct cost category hospitalization and in indirect cost category premature retirement were the main cost driver. From a societal perspective prevention and interventions focusing on disease control, and slowing down disease progression and strengthening the ability to work would be beneficial in order to realize cost savings in COPD.

Benefits of the 'village': a qualitative exploration of the patient experience of COPD in rural Australia

OBJECTIVES

This study sought to explore patients' experiences of living with, and adapting to, chronic obstructive pulmonary disease (COPD) in the rural context. Specifically, our research question was 'What are the barriers and facilitators to living with and adapting to COPD in rural Australia?'

DESIGN

Qualitative, semi-structured interviews. Conversations were recorded, transcribed verbatim and analysed using thematic analysis following the COnsolidated criteria for REporting Qualitative research guidelines.

SETTING

Patients with COPD, admitted to a subregional hospital in Australia were invited to participate in interviews between October and November 2016.

MAIN OUTCOME MEASURES

Themes were identified that assisted with understanding of the barriers and facilitators to living with, and adapting to, COPD in the rural context.

RESULTS

Four groups of themes emerged: internal facilitators (coping strategies; knowledge of when to seek help) and external facilitators (centrality of a known doctor; health team 'going above and beyond' and social supports) and internal/external barriers to COPD self-management (loss of identity, lack of access and clear communication, sociocultural challenges), which were moderated by feelings of inclusion or isolation in the rural community or 'village'.

CONCLUSIONS

Our findings suggest that community inclusion enhances patients' ability to cope and ultimately self-manage COPD. This is facilitated by living in a supportive 'village' environment, and included a central, known doctor and a healthcare team willing to go 'above and beyond'. Understanding, or supplementing, these social networks within the broader social structure may assist people to manage chronic disease, regardless of rural or metropolitan location.

Determinants of healthcare utilization and costs in COPD patients: first longitudinal results from the German COPD cohort COSYCONET

Background

In light of overall increasing healthcare expenditures, it is mandatory to study determinants of future costs in chronic diseases. This study reports the first longitudinal results on healthcare utilization and associated costs from the German chronic obstructive pulmonary disease (COPD) cohort COSYCONET.

Material and methods

Based on self-reported data of 1904 patients with COPD who attended the baseline and 18-month follow-up visits, direct costs were calculated for the 12 months preceding both examinations. Direct costs at follow-up were regressed on baseline disease severity and other co-variables to identify determinants of future costs. Change score models were developed to identify predictors of cost increases over 18 months. As possible predictors, models included GOLD grade, age, sex, education, smoking status, body mass index, comorbidity, years since COPD diagnosis, presence of symptoms, and exacerbation history.

Results

Inflation-adjusted mean annual direct costs increased by 5% (n.s., €6,739 to €7,091) between the two visits. Annual future costs were significantly higher in baseline GOLD grades 2, 3, and 4 (factors 1.24, 95%-confidence interval [1.07–1.43], 1.27 [1.09–1.48], 1.57 [1.27–1.93]). A history of moderate or severe exacerbations within 12 months, a comorbidity count >3, and the presence of dyspnea and underweight were significant predictors of cost increase (estimates ranging between + €887 and + €3,679, all p<0.05).

Conclusions

Higher GOLD grade, comorbidity burden, dyspnea and moderate or severe exacerbations were determinants of elevated future costs and cost increases in COPD. In addition we identified underweight as independent risk factor for an increase in direct healthcare costs over time.

Acceptance, adherence and dropout rates of individuals with COPD approached in telehealth interventions: a protocol for systematic review and meta-analysis

INTRODUCTION

Telehealth interventions have the potential of improving exacerbation and health outcomes for individuals with chronic obstructive pulmonary disease (COPD), by delivering care in between clinical visits. However, the precise impact on avoiding exacerbation and reducing the incidence of hospital readmissions remains inconclusive. This lack of knowledge on the effectiveness of telehealth for COPD care might be due to non-adherence or partial adherence to intervention programmes and/or the withdrawal of participants over the course of previous studies.

OBJECTIVES

To conduct a systematic review of trials of telehealth interventions (including randomised control trials (RCT), crossover and pre-post studies) to: (1) estimate the acceptance, adherence and dropout rates; (2) identify the reasons for dropout from telehealth interventions among individuals with COPD; (3) evaluate the impact of trial-related, sociodemographic and intervention-related factors on the acceptance, adherence and dropout rates and (4) estimate the extent to which the acceptance, adherence and dropout rates impact outcomes in comparison with usual monitoring.

METHODS AND ANALYSIS

A systematic literature review of four databases from earliest records to November 2018 will be carried out using CINAHL, Medline (Ovid), Cochrane Library and Embase. Randomised and non-randomised control studies will be included, in addition to crossover and pre-studies post-studies comparing telehealth with standard monitoring among individuals with COPD only. Two independent reviewers will screen all relevant abstracts and full-text studies to determine eligibility, assess the risk of bias and extract the data using structured forms. If the included studies are sufficiently homogenous in terms of interventions, populations and objectives, a meta-analysis will be performed.

ETHICS AND DISSEMINATION

Ethical considerations are not required for this research.

TRIAL REGISTRATION NUMBER

CRD42017078541.

Management of COPD within the Brazilian Unified Health Care System in the state of Bahia: an analysis of real-life medication use patterns

Objective:

To describe COPD pharmacological treatment patterns in the state of Bahia, Brazil, and to evaluate the extent to which these patterns conform to clinical guidelines for the management of COPD.

Methods:

This was a cross-sectional study of 441 patients referred from the Public Health Care Network of the state of Bahia to a public referral outpatient clinic of a COPD management program of the Brazilian Unified Health Care System. Individuals with a spirometry-confirmed diagnosis of moderate to very severe COPD were included in the study. Patients were evaluated as to whether they had used any COPD medications in the last seven days. The appropriateness or inappropriateness (undertreatment or overtreatment) of the patient’s pharmacological treatment was evaluated by comparing the patient’s current treatment with that recommended by national and international guidelines.

Results:

A total of 383 individuals were included in the analysis. Approximately half of the patients (49.1%) used long-acting bronchodilators. These patients were older and had had the disease longer. Of the sample as a whole, 63.7% and 83.0% did not receive pharmacological treatment in accordance with international and national recommendations, respectively. Inappropriateness due to undertreatment was indentified in more than half of the patients.

Conclusions:

Long-acting bronchodilators are frequently underused in individuals with moderate to very severe COPD within the Brazilian Unified Health Care System in the state of Bahia. Most patients in our sample were treated inappropriately, and undertreatment predominated. Strategies to improve access to long-acting bronchodilators and the quality of COPD pharmacological management are required.

The Economic Burden of Chronic Obstructive Pulmonary Disease in Greece

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a leading cause of disability and death worldwide, imposing a substantial socioeconomic burden on societies and patients due to the long-term management required.

OBJECTIVE

To assess the economic burden of COPD in Greece and its potential determinants.

METHODS

A population-based, random-digit dialled, telephone nationwide survey was conducted to recruit patients with COPD in Greece (N = 351). A structured questionnaire was used to collect data. The total annual cost per patient from a societal perspective was calculated.

RESULTS

The mean (95% CI) annual total cost per patient for the management of COPD from a societal perspective was €2150 (€1879-€2443). The total annual cost was mainly driven by the medication cost (36.1%), followed by the cost of hospitalizations (26.7%) and long-term oxygen therapy (13.8%). Multiple generalized linear model revealed that age, COPD Assessment Test (CAT) score and exacerbations were independently associated with the total annual cost.

CONCLUSION

Investment in interventions aiming at delaying progression of disease, preventing acute exacerbations, and managing chronic symptoms are required to reduce the overall economic burden of COPD in Greece.

Systematic review: chronic obstructive pulmonary disease and work-related outcomes

Background

Several studies have assessed the impact of chronic obstructive pulmonary disease (COPD) on work ability and work productivity; however, this relationship is poorly understood.

Aims

To undertake a systematic review to assess the effects of COPD on employment, absenteeism and presenteeism.

Methods

A comprehensive search using CINAHL, Embase, MEDLINE and the Cochrane Library was conducted to include epidemiological studies from 1937 to August 2017. One reviewer screened all citations. Shortlisted full-text articles were independently assessed by a second reviewer. Data were extracted by one reviewer with a random sample of papers (45%) checked by a second reviewer.

Results

Forty-four studies were included; the majority of evidence was from cross-sectional studies, and some cohort studies. COPD patients had lower employment rates than those without COPD. Among those in work, most studies showed patients with COPD took more time off work than those without and reported poorer work performance (presenteeism), although evidence for this association was weaker. The influence of disease severity on these outcomes was unclear; however, it appeared that increasing severity of airflow obstruction was associated with reduced likelihood of being employed. A number of methodological limitations were found among the evidence, including the lack of adjustment for important confounders.

Conclusions

Future studies are required which assess the impact of COPD on presenteeism using validated presenteeism instruments and consistent reporting methods. Robust studies are now needed to identify modifiable factors associated with these poorer working outcomes to inform future interventions aimed at improving work productivity among those with COPD.

Effect of Liuzijue Qigong on patients with chronic obstructive pulmonary disease: Protocol for a systematic review and meta-analysis

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide with a substantial and increasing social and economic burden. Liuzijue Qigong is a kind of traditional Chinese Qigong exercises that Traditional Chinese Medicine practitioners prescribe to individuals with COPD to strengthen the internal organs' function. Liuzijue Qigong was recommended for use in COPD rehabilitation, and some clinical trials indicate that Liuzijue Qigong would produce better functional capacity and quality of life of individuals with COPD. The objective of this study is to conduct a systematic review of the existing studies to assess effectiveness and safety of Liuzijue Qigong for the prevention or treatment of COPD in patients.

METHODS

We will perform the comprehensive literature search in English and Chinese electronic database. The publication period will be from inception to the search date. In addition, the clinical trial registries, dissertations, informal publication, grey literature, reference lists of studies, systematic reviews, and conference abstracts will also be collected. Two reviewers will identify relevant studies, extract data information, and then assess the methodical quality by the Cochrane risk of bias assessment tool. Only randomized controlled trials comparing Liuzijue Qigong against other intervention or nonintervention will be included. Data will be synthesized by either fixed-effect or random-effect model regarding to a heterogeneity test. The routine lung function, arterial blood gas tensions, partial pressure of carbon dioxide, functional capacity, 30 seconds sit-to-stand test, respiratory function, maximal inspiration pressure, maximal expiratory pressure, airway resistance, and specific airway conductance will be assessed as primary outcomes. The secondary outcomes involved dyspnea, and fatigue levels, respiratory muscle strength, upper and lower limb muscle strength, handgrip strength test, and health-related quality of life and safety. Meta-analysis will be performed by using Cochrane's Review Manager software (version 5.3.5).

RESULTS

This systematic review and meta-analysis will provide a high-quality synthesis and evaluate the efficacy and safety based on current relevant literature evidence of Liuzijue Qigong intervention for COPD patient.

CONCLUSION

Our systematic review will provide evidence to determine whether Liuzijue Qigong is an effective and safe approach to prevention and treatment of COPD patients.

Efficient computation of image moments for robust cough detection using smartphones

Health Monitoring apps for smartphones have the potential to improve quality of life and decrease the cost of health services. However, they have failed to live up to expectation in the context of respiratory disease. This is in part due to poor objective measurements of symptoms such as cough. Real-time cough detection using smartphones faces two main challenges namely, the necessity of dealing with noisy input signals, and the need of the algorithms to be computationally efficient, since a high battery consumption would prevent patients from using them. This paper proposes a robust and efficient smartphone-based cough detection system able to keep the phone battery consumption below 25% (16% if only the detector is considered) during 24 h use. The proposed system efficiently calculates local image moments over audio spectrograms to feed an optimized classifier for final cough detection. Our system achieves 88.94% sensitivity and 98.64% specificity in noisy environments with a 5500× speed-up and 4× battery saving compared to the baseline implementation. Power consumption is also reduced by a minimum factor of 6 compared to existing optimized systems in the literature.

COPD uncovered: a cross-sectional study to assess the socioeconomic burden of COPD in Japan

Background

COPD remains a major health problem in Japan. Patients with COPD experience a reduced quality of life (QoL) and have a higher chance of work impairment and productivity loss. However, there is a lack of data on the impact of COPD in terms of QoL and work activity impairment in Japan. This study assessed the socioeconomic burden of COPD in Japan and the impact it may have on the working age population.

Patients and methods

This was a 2-year retrospective chart review in COPD patients aged ≥40 years, with at least one health care visit to clinic or hospital in the previous 12 months. Patients were required to have available medical charts for at least the previous 24 months. Symptoms were assessed using COPD assessment test score; EuroQoL Group 5 Dimension (EQ-5D-5L) and work productivity and activity impairment general health questionnaires were used to evaluate health-related QoL and work productivity, and health care resource utilization data were obtained from clinical charts.

Results

In total, 71 patients aged <65 years, and 151 patients aged ≥65 years were included; the majority of patients had moderate or severe airflow limitation. Exacerbations (moderate or severe) were reported by ~35% of patients in both age groups; 52.1% and 62.9% of patients in the <65-year and ≥65-year age groups had COPD assessment test scores ≥10. EQ-5D-5L index scores in the <65-year and ≥65-year age groups were 0.79 and 0.77, respectively. Work productivity and activity impairment scores were higher in <65-year age group. Annual costs of health care resource use per patient in the <65-year and ≥65-year age groups were ¥438,975 (US$4,389) and ¥467,871 (US$4,678), respectively. Costs due to productivity loss were estimated to be ¥5,287,024 (US$52,870) in the <65-year age group and ¥3,018,974 (US$30,187) in the ≥65-year age group.

Conclusion

COPD represents a significant socioeconomic burden in Japan. Patients with COPD report significant use of health care resources. Higher impact on work impairment and productivity loss was observed frequently in the working age population.

Severity of Airflow Obstruction and Work Loss in a Nationwide Population of Working Age

The impact of COPD severity on labor force participation and work loss is not well known. This study aimed to describe the characteristics of occupations and to evaluate the reason for work loss based on the severity of airflow obstruction (AO). We performed a cross-sectional study using data from the Korean National Health and Nutrition Examination Survey V-VI. We identified 9,901 people aged 40 to 60 years who had normal or AO in spirometry test results. AO was defined as a pre-bronchodilator forced expiratory volume in 1 second/forced vital capacity <70%. AO was present in 7.6% of the subjects, and 81.5%, 82.9%, and 71.6% of subjects with mild, moderate, and severe-to-very severe AO were in the labor force, respectively. Multivariable analyses revealed that severe-to-very severe AO subjects were more likely to have precarious job (adjusted OR = 4.71, 95% CI = 1.70-13.06) and cite health-related problem as the reason for not being in the labor force (adjusted OR = 3.38, 95% CI = 1.03-11.02). Overall, AO was not associated with any significant changes in labor force participation. However, subjects with severe-to-very severe disease were more likely to drop out of the labor force owing to their health-related problems.

Disease burden of COPD in China: a systematic review

Chronic obstructive pulmonary disease (COPD) is one of the main contributors to the global burden of disease. The aim of this systematic review was to quantify the disease burden of COPD in China and to determine the risk factors of the disease. The number of studies included in the review was 47 with an average quality assessment score of 7.70 out of 10. Reported COPD prevalence varied between 1.20% and 8.87% in different provinces/cities across China. The prevalence rate of COPD was higher among men (7.76%) than women (4.07%). The disease was more prevalent in rural areas (7.62%) than in urban areas (6.09%). The diagnostic rate of COPD patients in China varied from 23.61% to 30.00%. The percentage of COPD patients receiving outpatient treatment was around 50%, while the admission rate ranged between 8.78% and 35.60%. Tobacco exposure and biomass fuel/solid fuel usage were documented as two important risk factors of COPD. COPD ranked among the top three leading causes of death in China. The direct medical cost of COPD ranged from 72 to 3,565 USD per capita per year, accounting for 33.33% to 118.09% of local average annual income. The most commonly used scales for the assessment of quality of life (QoL) included Saint George Respiratory Questionnaire, Airways Questionnaire 20, SF-36, and their revised versions. The status of QoL was worse among COPD patients than in non-COPD patients, and COPD patients were at higher risks of depression. The COPD burden in China was high in terms of economic burden and QoL. In view of the high smoking rate and considerable concerns related to air pollution and smog in China, countermeasures need to be taken to improve disease prevention and management to reduce disease burdens raised by COPD.

The health impacts of energy performance investments in low-income areas: a mixed-methods approach

Background

Cold homes and fuel poverty contribute to health inequalities in ways that could be addressed through energy efficiency interventions.

Objectives

To determine the health and psychosocial impacts of energy performance investments in low-income areas, particularly hospital admissions for cardiorespiratory conditions, prevalence of respiratory symptoms and mental health status, hydrothermal conditions and household energy use, psychosocial outcomes, cost consequences to the health system and the cost utility of these investments.

Design

A mixed-methods study comprising data linkage (25,908 individuals living in 4968 intervention homes), a field study with a controlled pre-/post-test design (intervention,n = 418; control,n = 418), a controlled multilevel interrupted time series analysis of internal hydrothermal conditions (intervention,n = 48; control,n = 40) and a health economic assessment.

Setting

Low-income areas across Wales.

Participants

Residents who received energy efficiency measures through the intervention programme and matched control groups.

Main outcome measures

Primary outcomes – emergency hospital admissions for cardiorespiratory conditions, self-reported respiratory symptoms, mental health status, indoor air temperature and indoor relative humidity. Secondary outcomes – emergency hospital admissions for chronic obstructive pulmonary disease-related cardiorespiratory conditions, excess winter admissions, health-related quality of life, subjective well-being, self-reported fuel poverty, financial stress and difficulties, food security, social interaction, thermal satisfaction and self-reported housing conditions.

Methods

Anonymously linked individual health records for emergency hospital admissions were analysed using mixed multilevel linear models. A quasi-experimental controlled field study used a multilevel repeated measures approach. Controlled multilevel interrupted time series analyses were conducted to estimate changes in internal hydrothermal conditions following the intervention. The economic evaluation comprised cost–consequence and cost–utility analyses.

Data sources

The Patient Episode Database for Wales 2005–14, intervention records from 28 local authorities and housing associations, and scheme managers who delivered the programme.

Results

The study found no evidence of changes in physical health. However, there were improvements in subjective well-being and a number of psychosocial outcomes. The household monitoring study found that the intervention raised indoor temperature and helped reduce energy use. No evidence was found of substantial increases in indoor humidity levels. The health economic assessment found no explicit cost reductions to the health service as a result of non-significant changes in emergency admissions for cardiorespiratory conditions.

Limitations

This was a non-randomised intervention study with household monitoring and field studies that relied on self-response. Data linkage focused on emergency admissions only.

Conclusion

Although there was no evidence that energy performance investments provide physical health benefits or reduce health service usage, there was evidence that they improve social and economic conditions that are conducive to better health and improved subjective well-being. The intervention has been successful in reducing energy use and improving the living conditions of households in low-income areas. The lack of association of emergency hospital admissions with energy performance investments means that we were unable to evidence cost saving to health-service providers.

Future work

Our research suggests the importance of incorporating evaluations with follow-up into intervention research from the start.

Funding

The National Institute for Health Research Public Health Research programme.

Robust Detection of Audio-Cough Events Using Local Hu Moments

Telehealth has shown potential to improve access to healthcare cost-effectively in respiratory illness. However, it has failed to live up to expectation, in part because of poor objective measures of symptoms such as cough events, which could lead to early diagnosis or prevention. Considering the burden that these conditions constitute for national health systems, an effort is needed to foster telehealth potential by developing low-cost technology for efficient monitoring and analysis of cough events. This paper proposes the use of local Hu moments as a robust feature set for automatic cough detection in smartphone-acquired audio signals. The final system feeds a k-nearest-neighbor classifier with the extracted features. To properly evaluate the system in a diversity of noisy backgrounds, we contaminated real cough audio data with a variety of sounds including noise from both indoor and outdoor environments and noncough events (sneeze, laugh, speech, etc.). The created database allows flexible settings of signal-to-noise ratio levels between background sounds and events (cough and noncough). This evaluation was complemented using real patient data from an outpatient clinic. The system is able to detect cough events with high sensitivity (up to 88.51%) and specificity (up to 99.77%) in a variety of noisy environments, overcoming other state-of-the-art audio features. Our proposal paves the way for ubiquitous cough monitoring with minimal disruption in daily activities.

Trends in health care resource utilization and pharmacological management of COPD in Taiwan from 2004 to 2010

RATIONALE

COPD has attracted widespread attention worldwide. The prevalence of COPD in Taiwan has been reported, but little is known about trends in health care resource utilization and pharmacologic management in COPD treatment.

OBJECTIVE

The objective of this article was to study trends in health care resource utilization, pharmacologic management, and medical costs of COPD treatment in Taiwan.

MATERIALS AND METHODS

Reimbursement claims in the Taiwan National Health Insurance System from 2004 to 2010 were collected. The disease burden of COPD, including health care resource utilization and medical costs, was evaluated.

RESULTS

The pharmacy cost of COPD increased from 2004 to 2010 due to the increased utilization of long-acting muscarinic antagonist (LAMA) and fixed-dose combination of long-acting β2-agonist and inhaled corticosteroid (LABA/ICS), whereas the cost of all other COPD-related medications decreased. The average outpatient department (OPD) cost per patient increased 29.3% from 1,070 USD in 2004 to 1,383 USD in 2010. The highest average total medical cost per patient was 3,434 USD in 2005, and it decreased 12.4% to 3,008 USD in 2010. There was no significant difference in the average number of OPD visits and emergency department visits per patient. The highest average number of hospital admissions was 0.81 in 2005, and it decreased to 0.65 in 2010. The average number of intensive care unit (ICU) admissions decreased from 0.52 in 2005 to 0.31 in 2010.

CONCLUSION

From 2004 to 2010, the average total medical cost per patient of COPD was slightly decreased because of the decreased average number of hospital admissions and ICU admissions. The costs of both LAMA and LABA/ICS increased, while the cost for all other COPD-related medications decreased. These findings suggest that the increased utilization of LAMA and LABA/ICS may have contributed to the decreased average number of hospital admissions and ICU admissions in COPD patients from 2004 to 2010.

Factors associated with work productivity among people with COPD: Birmingham COPD Cohort

BACKGROUND

Patients with chronic obstructive pulmonary disease (COPD) are more likely to take time off work (absenteeism) and report poor performance at work (presenteeism) compared to those without COPD. Little is known about the modifiable factors associated with these work productivity outcomes.

AIM

To assess the factors associated with work productivity among COPD patients.

METHODS

Cross-sectional analysis of baseline data from a subsample (those in paid employment) of the Birmingham COPD Cohort study. Absenteeism was defined by self-report over the previous 12 months. Presenteeism was assessed using the Stanford Presenteeism Scale. Logistic regression analysis was used to assess the effects of sociodemographic, clinical and occupational characteristics on work productivity.

RESULTS

Among 348 included participants, increasing dyspnoea was the only factor associated with both absenteeism and presenteeism (p for trend<0.01). Additionally, increasing history of occupational exposure to vapours, gases, dusts or fumes (VGDF) was independently associated with presenteeism (p for trend<0.01).

CONCLUSIONS

This is the first study to identify important factors associated with poor work productivity among patients with COPD. Future studies should evaluate interventions aimed at managing breathlessness and reducing occupational exposures to VGDF on work productivity among patients with COPD.

A Novel Remote Rehabilitation System with the Fusion of Noninvasive Wearable Device and Motion Sensing for Pulmonary Patients

Chronic obstructive pulmonary disease is a type of lung disease caused by chronically poor airflow that makes breathing difficult. As a chronic illness, it typically worsens over time. Therefore, pulmonary rehabilitation exercises and patient management for extensive periods of time are required. This paper presents a remote rehabilitation system for a multimodal sensors-based application for patients who have chronic breathing difficulties. The process involves the fusion of sensory data-captured motion data by stereo-camera and photoplethysmogram signal by a wearable PPG sensor-that are the input variables of a detection and evaluation framework. In addition, we incorporated a set of rehabilitation exercises specific for pulmonary patients into the system by fusing sensory data. Simultaneously, the system also features medical functions that accommodate the needs of medical professionals and those which ease the use of the application for patients, including exercises for tracking progress, patient performance, exercise assignments, and exercise guidance. Finally, the results indicate the accurate determination of pulmonary exercises from the fusion of sensory data. This remote rehabilitation system provides a comfortable and cost-effective option in the healthcare rehabilitation system.

Telehealthcare for patients suffering from chronic obstructive pulmonary disease: effects on health-related quality of life: results from the Danish 'TeleCare North' cluster-randomised trial

OBJECTIVE

To assess the effect of telehealthcare compared with usual practice in patients with chronic obstructive pulmonary disease (COPD).

DESIGN

A cluster-randomised trial with 26 municipal districts that were randomly assigned either to an intervention group whose members received telehealthcare in addition to usual practice or to a control group whose members received usual practice only (13 districts in each arm).

SETTING

Twenty-six municipal districts in the North Denmark Region of Denmark.

PARTICIPANTS

Patients who fulfilled the Global Initiative for COPD guidelines and one of the following criteria: COPD Assessment Test score ≥10; or Medical Research Dyspnoea Council Scale ≥3; or Modified Medical Research Dyspnoea Council Scale ≥2; or ≥2 exacerbations during the past 12 months.

MAIN OUTCOME MEASURES

Health-related quality of life (HRQoL) assessed by the physical component summary (PCS) and mental component summary (MCS) scores of the Short Form 36-Item Health Survey, Version 2. Data were collected at baseline and at 12 month follow-up and analysed according to the intention-to-treat principle with complete cases, n=574 (258 interventions; 316 controls) and imputed data, n=1225 (578 interventions, 647 controls) using multilevel modelling.

RESULTS

In the intention-to-treat analysis (n=1225), the raw mean difference in PCS from baseline to 12 month follow-up was -2.6 (SD 12.4) in the telehealthcare group and -2.8 (SD 11.9) in the usual practice group. The raw mean difference in MCS scores in the same period was -4.7 (SD 16.5) and -5.3 (SD 15.5) for telehealthcare and usual practice, respectively. The adjusted mean difference in PCS and MCS between groups at 12 months was 0.1 (95% CI -1.4 to 1.7) and 0.4 (95% CI -1.7 to 2.4), respectively.

CONCLUSIONS

The overall sample and all subgroups demonstrated no statistically significant differences in HRQoL between telehealthcare and usual practice.

TRIAL REGISTRATION NUMBER

NCT01984840; Results.

Clinical characteristics, treatment patterns, and socio-economic burden of COPD in Bulgaria

BACKGROUND

While the impact of COPD in Western-Europe is known, data from Eastern-Europe is scarce. This study aimed to evaluate clinical characteristics, treatment patterns, and the socio-economic burden of COPD in Eastern-Europe, taking Bulgaria as a reference case.

METHODS

A representative sample of Bulgarian patients with COPD was randomly chosen by pulmonologists, based on the following inclusion criteria: COPD diagnosis with at least 1 year of living with COPD, ≥40 years of age, and use of COPD medication. Patient characteristics, treatment, quality-of-life, healthcare resource use, and costs were systematically assessed.

RESULTS

A total of 426 COPD patients were enrolled. Approximately 69% were male, 40% had occupational risk factors, 45% had severe and 11% had very severe COPD. Mean CAT scores were 13.80 (GOLD A), 21.80 (GOLD B), 17.35 (GOLD C), and 26.70 (GOLD D). Annual per-patient costs of healthcare utilization were €579. Yearly pharmacotherapy costs were €693. Indirect costs (reduced and lost work productivity) outnumbered direct costs three times.

CONCLUSIONS

Bulgaria has relatively high percentages of (very) severe COPD patients, resulting in considerable socio-economic burden. High smoking rates, occupational risk factors, air pollution, and a differential health system may be related to this finding. Eastern-European COPD strategies should focus on prevention, risk-factor awareness, and early detection.

Daily Symptom Variability in Patients With Stable COPD: A Narrative Review

Daily symptom variability refers to the fluctuation of chronic obstructive pulmonary disease (COPD) symptoms over the day. Although most clinicians can describe the day-to-day variation in symptoms experienced by patients with COPD, little has been done to quantify the variability. This review aims to synthesize evidence of daily symptom variability among patients with stable COPD. Of the 325 potentially relevant articles that were retrieved, 11 observational articles were finally included in the review. Patients with stable COPD commonly experience daily symptom variability, with morning being the most troublesome time of day, followed by night. Morning symptoms had a significant effect on morning routines or daily activities, and night-time symptoms affected the sleep quality of patients. In comparison with patients without symptom variability, patients with morning/night-time symptoms or symptom variability exhibited poorer health status as well as greater disease severity and incidence of exacerbation.