Health-related quality of life and chronic obstructive pulmonary disease in early stages - longitudinal results from the population-based KORA cohort in a working age population

Factors influencing health-related quality of life in patients with chronic obstructive pulmonary disease: insights from the Burden of Obstructive Lung Disease Study in Fez, Morocco

The respiratory symptoms experienced by patients with chronic obstructive pulmonary disease (COPD) are a burden on daily life. The objective of this study was to measure health-related quality of life (HRQoL) and comprehensively identify its associated factors in Moroccan COPD patients. A cross-sectional, randomized study was carried out in the city of Fes, Morocco, as part of the large multicenter Burden of Obstructive Lung Disease Study on people with COPD. Data collection was carried out using a questionnaire containing sociodemographic, clinical, and quality-of-life data. The diagnosis of COPD was based on spirometry, and quality of life was measured by the Short Form Survey (SF-12) questionnaire. Using multiple linear regression, we assessed the relationship between several sociodemographic and clinical factors and SF-12 mental and physical quality-of-life scores. A total of 107 patients were included, with a male predominance (63.6%) and the most common age category being 60 years and older (51.4%). Additionally, 46.7% of participants were classified as Global Initiative for Obstructive Lung Disease (GOLD) stage 1. The mean SF-12 mental component score was 41.32±9.18, and the mean SF-12 physical component score was 41.91±11.93. Multivariate analysis revealed that a greater mental HRQoL was associated with the male gender, a body mass index of 25 or higher, and GOLD stage 1, while a greater physical HRQoL was associated with the male gender, an age less than 60 years, absence of respiratory comorbidities, and GOLD stage 1. Our results show low scores of the mental and physical components of HRQoL in COPD patients in Morocco, suggesting the implementation of measures to reduce first the prevalence of the disease and then adopt an appropriate COPD management strategy to improve those people's quality of life.

Patient experience with chronic obstructive pulmonary disease: a nationally representative demonstration study on quality and cost of healthcare services

Introduction

Due to insufficient data on patient experience with healthcare system among patients with chronic obstructive pulmonary disease (COPD), particularly in developing countries, this study attempted to investigate the journey of patients with COPD in the healthcare system using nationally representative data in Iran.

Methods

This nationally representative demonstration study was conducted from 2016 to 2018 using a novel machine-learning based sampling method based on different districts' healthcare structures and outcome data. Pulmonologists confirmed eligible participants and nurses recruited and followed them up for 3  months/in 4 visits. Utilization of various healthcare services, direct and indirect costs (including non-health, absenteeism, loss of productivity, and time waste), and quality of healthcare services (using quality indicators) were assessed.

Results

This study constituted of a final sample of 235 patients with COPD, among whom 154 (65.5%) were male. Pharmacy and outpatient services were mostly utilized healthcare services, however, participants utilized outpatient services less than four times a year. The annual average direct cost of a patient with COPD was 1,605.5 USDs. Some 855, 359, 2,680, and 933 USDs were imposed annually on patients with COPD due to non-medical costs, absenteeism, loss of productivity, and time waste, respectively. Based on the quality indicators assessed during the study, the focus of healthcare providers has been the management of the acute phases of COPD as the blood oxygen levels of more than 80% of participants were documented by pulse oximetry devices. However, chronic phase management was mainly missed as less than a third of participants were referred to smoking and tobacco quit centers and got vaccinated. In addition, less than 10% of participants were considered for rehabilitation services, and only 2% completed four-session rehabilitation services.

Conclusion

COPD services have focused on inpatient care, where patients experience exacerbation of the condition. Upon discharge, patients do not receive appropriate follow-up services targeting on preventive care for optimal controlling of pulmonary function and preventing exacerbation.

Investigation on the Relationship between Sleep Quality and Depression and Anxiety in Hospitalized Patients with Different Levels of AECOPD

Purpose

To explore the correlations between sleep quality and depression and anxiety in hospitalized patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD).

Methods

A total of 131 AECOPD patients treated at No.6th People's Hospital affiliated to Shanghai Jiao Tong University School from January 2018 to December 2020 were selected and divided into the classes I (n = 30), II (n = 23), III (n = 37), and IV (n = 41) based on the severity of AECOPD. The Pittsburgh sleep quality index (PSQI) and the hospital anxiety and depression scale (HADS) were employed to assess the quality of sleep and anxiety/depression in AECOPD patients. The Pearson correlation analysis explored the associations between PSQI score and HADS anxiety/depression score. Binary logistic regression was utilized to determine risk factors for anxiety/depression in AECOPD patients.

Results

The PSQI score, HADS anxiety score, and HADS depression score in patients with AECOPD class III and class IV were significantly higher than those of classes I and II. The severe anxiety and depression ratio were significantly different among patients with classes I-IV AECOPD. The severity of AECOPD was significantly correlated with the PSQI score (r = 0.51, P < 0.001), HADS anxiety score (r = 0.66, P < 0.001), and HADS anxiety score (r = 0.65, P < 0.001). Binary logistic regression analysis showed that the COPD duration, the severity of AECOPD, and PSQI score were the risk factors for anxiety and depression in patients with AECOPD.

Conclusions

Poor sleep quality, anxiety, and depression are common in patients with AECOPD. Improvement of sleep quality may help to alleviate anxiety and depression in AECOPD patients.

Significance of FEV3/FEV6 in recognition of early airway disease in smokers at risk of development of COPD: Analysis of the SPIROMICS cohort

BACKGROUND

Small airways are known to be affected early in the course of chronic obstructive pulmonary disease (COPD); however, traditional spirometric indices may not accurately identify small airways disease.

RESEARCH QUESTION

Can FEV₃/FEV₆ identify early airflow abnormalities and predict future clinically important respiratory-related outcomes, including development of COPD?

STUDY DESIGN AND METHODS

We included eight hundred thirty-two current and former smokers with post-bronchodilator FEV₁/FVC ≥0.7 from the SPIROMICS cohort. Participants were classified as having a reduced pre-bronchodilator FEV₃/FEV₆ based on lower limit of normal (LLN) values. Repeatability analysis was performed for FEV₃ and FEV₆. Regression modeling was used to evaluate the relationship between baseline FEV₃/FEV₆ and outcome measures including functional small airways disease on thoracic imaging and respiratory exacerbations. Interval censored analysis was used to assess progression to COPD.

RESULTS

FEV₃/FEV₆ <LLN at baseline, defined as reduced compared to FEV₃/FEV₆ ≥LLN, was associated with lower FEV₁, poorer health status (St. George's Respiratory Questionnaire score), more emphysema, and more functional small airways disease on quantitative imaging. FEV₃ and FEV₆ showed excellent agreement between repeat measurements. A reduced FEV₃/FEV₆ was associated with increased odds of a severe respiratory exacerbation within the first year of follow-up and decreased time to first exacerbation. A low FEV₃/FEV₆ was also associated with development of COPD by spirometry (post-bronchodilator FEV₁/FVC <0.7) during study follow-up.

INTERPRETATION

FEV₃/FEV₆ is a routinely available and repeatable spirometric index which can be useful in the evaluation of early airflow obstruction in current and former smokers without COPD. A reduced FEV₃/FEV₆ can identify those at risk for future development of COPD and respiratory exacerbations.

Similarities and Differences of Mental Health in Women and Men: A Systematic Review of Findings in Three Large German Cohorts

In Germany, large, population-based cohort studies have been implemented in order to identify risk and protective factors for maintaining health across the life span. The purpose of this systematic review is to analyse findings from three large ongoing cohorts and to identify sex-specific prevalence rates, risk and protective factors for mental health. Published studies from the Cooperative Health Research in the Region Augsburg (KORA), the Study of Health in Pomerania (SHIP) and the Gutenberg Health Study (GHS)), representing the southern, north-eastern and middle parts of Germany, were identified through searches of the databases PubMed and Web of Science. A total of 52 articles was identified from the start of each cohort until June 2019. Articles reporting prevalence rates of mental health [N = 22], explanatory factors for mental health [N = 25], or both [N = 5] were identified. Consistent across cohorts, higher prevalence rates of internalizing disorders were found for women and more externalizing disorders for men. Risk and protective factors for mental health included social factors, lifestyle, physical health, body mass index (BMI), diabetes, genetic and biological factors. In all areas, differences and similarities were found between women and men. The most evident were the sex-specific risk profiles for depression with mostly external risk factors for men and internal risk factors for women. Gender was not assessed directly, therefore we examined whether socioeconomic and family-related factors reflecting gender roles or institutionalized gender could be used as a proxy for gender. Overall, this systematic review shows differences and similarities in prevalence rates and determinants of mental health indicators between women and men. They underline the importance of focussing on sex specific approaches in mental health research and in the development of prevention measures. Current research on mental health still lacks focus on gender aspects. Therefore, an increased focus on sex and gender in mental health research is of great importance.

Quantifying heterogeneity of physical and mental health-related quality of life in chronic obstructive pulmonary disease patients in the United States

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a heterogenous condition. This study aims to quantify the heterogeneity of Health-related Quality of Life (HRQoL), and identify subgroups with the lowest HRQoL, in COPD patients in the United States (US). Methods Data from 2008-2015 Medical Expenditure Panel Survey were used to examine the heterogeneity of HRQoL between different COPD subgroups using mixed-effects modeling and G-computation. The Physical Composite Summary (PCS) and Mental Composite Summary (MCS) scores from the Short-Form-12 questionnaire were utilized. We also compared the heterogeneity of HRQoL in our COPD cohort against that in a matched non-COPD cohort. Results The final sample consisted of 1,866 (weighted = 19,952,143) COPD patients with a mean age of 63.2 years (Standard error (SE):0.38), mean MCS score of 46.84 (SE:0.35), and mean PCS score of 35.65 (SE:0.32). The adjusted MCS and PCS scores ranged from 36.19 to 53.06, and from 25.52 to 48.27, respectively, for COPD subgroups. COPD patients had statistically significantly lower MCS and PCS scores by 4.61, and 5.86 points, respectively, compared to the matched non-COPD cohort, and MCS scores showed a wider variability in the COPD cohort. Conclusion Our study quantifies substantial heterogeneity of HRQoL in COPD in the US and provides evidence for prioritizing COPD subgroups with the lowest HRQoL for targeted interventions.

Management of the COPD Patient with Comorbidities: An Experts Recommendation Document

Background

Chronic obstructive pulmonary disease (COPD) is associated with multiple comorbidities, which impact negatively on patients and are often underdiagnosed, thus lacking a proper management due to the absence of clear guidelines.

Purpose

To elaborate expert recommendations aimed to help healthcare professionals to provide the right care for treating COPD patients with comorbidities.

Methods

A modified RAND-UCLA appropriateness method consisting of nominal groups to draw up consensus recommendations (6 Spanish experts) and 2-Delphi rounds to validate them (23 Spanish experts) was performed.

Results

A panel of Spanish internal medicine experts reached consensus on 73 recommendations and 81 conclusions on the clinical consequences of the presence of comorbidities. In general, the experts reached consensus on the issues raised with regard to cardiovascular comorbidity and metabolic disorders. Consensus was reached on the use of selective serotonin reuptake inhibitors in cases of depression and the usefulness of referring patients with anxiety to respiratory rehabilitation programmes. The results also showed consensus on the usefulness of investigating the quality of sleep, the treatment of pain with opioids and the evaluation of osteoporosis by lateral chest radiography.

Conclusion

This study provides conclusions and recommendations that are intended to improve the management of the complexity of patients with COPD and important comorbidities, usually excluded from clinical trials.

[Lung function in the German National Cohort: methods and initial results]

BACKGROUND

A nationwide assessment of the respiratory status on the basis of standardized lung function measurements has so far not been available in Germany. The present work describes the lung function tests in the German National Cohort (GNC) and presents initial results based on the GNC Midterm Baseline Dataset.

MATERIAL AND METHODS

The assessment of lung function in the GNC comprised spirometry (level 1) and the determination of exhaled nitric oxide (FeNO, level 2). Our quality assurance concept included regular training of lung function test procedures at various GNC sites, interim evaluations of test quality, as well as regular calibration/measurement checks of test equipment. For spirometry, we established a stepwise procedure for offline quality control based on raw flow volume curves.

RESULTS

In the present dataset (n = 101,734), spirometry was available for 86,893 study participants and FeNO was available for 15,228 participants. The average (±SD) FEV₁ Z score (according to GLI 2012) was -0.321 ± 1.047, the FVC Z score was -0.153 ± 0.941, and the FEV₁/FVC Z score was -0.337 ± 0.901. The difference in FEV₁/FVC between current smokers and never-smokers increased with age. The average FeNO was 14.2 ÷ 2.0 ppb. Current smoking reduced FeNO levels by 43%, whereas respiratory allergy increased FeNO levels by 16% in nonsmokers.

DISCUSSION

The results of spirometry and the FeNO measurements are in the expected range with regard to their distributions and correlates. The GNC provides a valuable basis for future investigations of respiratory health and its determinants as well as research into the prevention of respiratory diseases in Germany.

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.

Influence of comorbid heart disease on dyspnea and health status in patients with COPD - a cohort study

Purpose

The aim of this study was to examine the changing influence over time of comorbid heart disease on symptoms and health status in patients with COPD.

Patients and methods

This is a prospective cohort study of 495 COPD patients with a baseline in 2005 and follow-up in 2012. The study population was divided into three groups: patients without heart disease (no-HD), those diagnosed with heart disease during the study period (new-HD) and those with heart disease at baseline (HD). Symptoms were measured using the mMRC. Health status was measured using the Clinical COPD Questionnaire (CCQ) and the COPD Assessment Test (CAT; only available in 2012). Logistic regression with mMRC ≥2 and linear regression with CCQ and CAT scores in 2012 as dependent variables were performed unadjusted, adjusted for potential confounders, and additionally adjusted for baseline mMRC, respectively, CCQ scores.

Results

Mean mMRC worsened from 2005 to 2012 as follows: for the no-HD group from 1.8 (±1.3) to 2.0 (±1.4), (P=0.003), for new-HD from 2.2 (±1.3) to 2.4 (±1.4), (P=0.16), and for HD from 2.2 (±1.3) to 2.5 (±1.4), (P=0.03). In logistic regression adjusted for potential confounding factors, HD (OR 1.71; 95% CI: 1.03-2.86) was associated with mMRC ≥2. Health status worsened from mean CCQ as follows: for no-HD from 1.9 (±1.2) to 2.1 (±1.3) with (P=0.01), for new-HD from 2.3 (±1.5) to 2.6 (±1.6) with (P=0.07), and for HD from 2.4 (±1.1) to 2.5 (±1.2) with (P=0.57). In linear regression adjusted for potential confounders, HD (regression coefficient 0.12; 95% CI: 0.04-5.91) and new-HD (0.15; 0.89-5.92) were associated with higher CAT scores. In CCQ functional state domain, new-HD (0.14; 0.18-1.16) and HD (0.12; 0.04-0.92) were associated with higher scores. After additional correction for baseline mMRC and CCQ, no statistically significant associations were found.

Conclusion

Heart disease contributes to lower health status and higher symptom burden in COPD but does not accelerate the worsening over time.

Effects of pulmonary rehabilitation in patients with mild-to-moderate chronic obstructive pulmonary disease: Bottom of an iceberg

OBJECTIVES

This study aims to compare the effects of pulmonary rehabilitation (PR) in patients with mild-to-moderate and severe-to-very severe chronic obstructive pulmonary disease (COPD).

PATIENTS AND METHODS

Between January 2005 and December 2010, a total of 76 patients with mild-to-moderate (Global Initiative for Chronic Obstructive Lung Disease [GOLD] Stages I+II, n=33, mean age 66.0±8.6 years) and severe-to-very severe (GOLD Stages III+IV, n=43, mean age 63.5±8.8 years) COPD completed an eight-week outpatient PR program. Incremental and endurance shuttle walk tests (ISWT, ESWT), St. George's Respiratory Questionnaire (SGRQ), Chronic Respiratory Questionnaire (CRQ), and Hospital Anxiety and Depression Scale were assessed before and after PR. Changes after the intervention were compared between two groups.

RESULTS

There were significant improvements in the ISWT and median 60 m [(-150)-(400)] in mild-to-moderate group and 70 m [(0)-(270)] in severe-to-very severe group (both, p<0.001). The ESWT time improved in both groups, 122s [(-279)-(665)] (p=0.002) and 61s [(-180)- (878)] (p<0.001), respectively. Significant effects were observed in all domains of the SGRQ except the impact score in mild-to-moderate patients. There were significant improvements in all domains except the symptoms score in severe-to-very severe patients. Using the CRQ, a significant improvement was shown in all domains of CRQ except the dyspnea score of mild-to-moderate patients. Anxiety and depression scores decreased after PR in both groups (p<0.05). According to changes in outcomes, there was no difference in any parameters between two groups.

CONCLUSION

This study demonstrates that patients with mild-to-moderate COPD benefit from PR comparably to patients with severe-to- very-severe COPD. Although patients with mild-to-moderate COPD are not usually symptomatic, our findings suggest that they should be included in PR.

Association of generic health-related quality of life (EQ-5D dimensions) and inactivity with lung function in lung-healthy German adults: results from the KORA studies F4L and Age

PURPOSE

Among patients with lung disease, decreased lung function is associated with lower health-related quality of life. However, whether this association is detectable within the physiological variability of respiratory function in lung-healthy populations is unknown. We analyzed the association of each EQ-5D-3L dimension (mobility, self-care, usual activities, pain/discomfort, anxiety/depression) and self-reported physical inactivity with spirometric indices in lung-healthy adults. Modulating effects between inactivity and EQ-5D dimensions were considered.

METHODS

1132 non-smoking, apparently lung-healthy participants (48% male, aged 64 ± 12 years) from the population-based KORA F4L and Age surveys in Southern Germany were analyzed. Associations of each EQ-5D dimension and inactivity with spirometric indices serving as outcomes (forced expiratory volume in 1 s (FEV₁), forced vital capacity (FVC), FEV₁/FVC, and mid-expiratory flow) were examined by linear regression, considering possible confounders. Interactions between EQ-5D dimensions (no problems/any problems) and inactivity (four categories of time spent engaging in exercise: inactive to most active) were assessed.

RESULTS

Among all participants 42% reported no problems in any EQ-5D dimension, 24% were inactive and 32% exercised > 2 h/week. After adjustment, FEV₁ was - 99 ml (95% CI - 166; - 32) and FVC was - 109 ml (95% CI - 195; - 24) lower among subjects with mobility problems. Comparable estimates were observed for usual activities. Inactivity was negatively associated with FVC (β-coefficient: - 83 ml, 95% CI - 166; 0), but showed no interactions with EQ-5D.

CONCLUSIONS

Problems with mobility or usual activities, and inactivity were associated with slightly lower spirometric parameters in lung-healthy adults, suggesting a relationship between perceived physical functioning and volumetric lung function.

Factors associated with generic health-related quality of life (HRQOL) in patients with chronic obstructive pulmonary disease (COPD): a cross-sectional study

Background

Health-related quality of life (HRQOL) is impaired in chronic obstructive pulmonary disease (COPD) patients, but determining factors for HRQOL are still not unequivocal. This study measures HRQOL among patients with COPD and aims to determine factors associated with HRQOL.

Methods

Data for cross-sectional analyses were obtained from the baseline of a cohort study. The study population includes adult COPD patients (disease duration ≥3 months), recruited from primary and secondary care settings in Germany, without acute psychiatric/neurologic disease (exception: affective/ anxiety disorders). HRQOL was assessed using the Short-Form 12 (SF-12) Health Survey Questionnaire, comprising a physical and mental component. Independent variables encompass socio-demographic, disease-specific, treatment-related and psychological factors. Multivariable linear regression analyses were conducted.

Results

In total, 206 COPD patients (60.7% male; mean age: 65.3 years) took part in the study. In multivariable analysis, the physical component score showed a significant negative association with the COPD Assessment Test (CAT) (P<0.001) and a higher total number of prescribed medications (P=0.001). A higher forced expiratory volume in 1 second (FEV1) value in percent predicted was significantly related to the physical component score in a positive manner (P=0.006). The mental component score was significantly associated with elevated patient-reported symptoms of anxiety (P=0.002) or depression (P<0.001), measured by the hospital anxiety and depression scale (HADS) in a negative way. Like for the physical component score (P<0.001), a worse CAT score was significantly associated with a lower mental component score (P=0.033).

Conclusions

Focusing on patient reported outcomes and screening for depression and anxiety with potential successive treatment might be promising approaches to improve HRQOL in patients with COPD.

Perceived Satisfaction With Long-Term Oxygen Delivery Devices Affects Perceived Mobility and Quality of Life of Oxygen-Dependent Individuals With COPD

BACKGROUND

Although routine physical activity for individuals with COPD is recommended, there are inherent limitations of available oxygen delivery devices that may result in hypoxemia during activity. Changes in Medicare laws have resulted in an increased use of oxygen cylinders and a reduction in the use of liquid oxygen devices. The aim of this survey was to assess the impact of perceived satisfaction with various oxygen delivery devices on perceived mobility and quality of life (QOL) of oxygen-dependent subjects with COPD.

METHODS

A survey was developed to measure perceived satisfaction with current portable oxygen delivery devices, perceived mobility, and perceived QOL. The survey was deployed via a link posted on the COPD Foundation's COPD360SOCIAL social media site for 5 weeks, which resulted in the recruitment of 529 participants, of which 417 were included in the data analysis.

RESULTS

Quantile regression analysis revealed that the median perceived device satisfaction score was significantly higher in the liquid oxygen device group (P < .001) compared with the portable oxygen cylinder and portable oxygen concentrator (POC) groups. The median perceived mobility score was significantly higher in the liquid oxygen device group (P < .001) compared with the portable oxygen cylinder group, but not the POC group. The median QOL score was significantly higher in the liquid oxygen device group (P < .001) compared with the POC and portable oxygen cylinder groups. Moreover, partial least-squares structural equation modeling regression analysis showed that perceived mobility is significantly affected by perceived satisfaction with the long-term oxygen therapy (LTOT) device (adjusted R² = 0.15, P < .001), and perceived QOL is significantly affected by both perceived satisfaction with the LTOT device and perceived mobility (adjusted R² = 0.45, P < .001).

CONCLUSIONS

For individuals with COPD requiring LTOT, perceived satisfaction with a portable LTOT device significantly and positively affects perceived mobility and QOL.

Effect of tiotropium and olodaterol on symptoms and patient-reported outcomes in patients with COPD: results from four randomised, double-blind studies

Chronic obstructive pulmonary disease is associated with significant morbidity and mortality. Trials of maintenance chronic obstructive pulmonary disease treatments focus on improvement in lung function and reductions in exacerbations, while patients are much more concerned about symptoms and health status. Our aim was to investigate the effects of tiotropium + olodaterol on patient-reported health outcomes, breathlessness and night-time rescue medication use in patients with chronic obstructive pulmonary disease, compared to placebo, tiotropium or olodaterol monotherapy. Two pairs of replicate, phase III studies of 12 (OTEMTO 1 + 2) and 52 weeks’ (TONADO 1 + 2) duration were evaluated, in which patients received either tiotropium + olodaterol 2.5/5 or 5/5 μg, tiotropium 2.5 or 5 μg, olodaterol 5 μg or placebo, all delivered once daily via Respimat inhaler. Patient-reported outcomes included breathlessness assessed by transition dyspnoea index focal score, health status assessed by St George’s Respiratory Questionnaire total score and night-time rescue medication use at 12 or 24 weeks. Outcomes from the pooled study data are reported. Overall, 1621 and 5162 patients were treated in the OTEMTO and TONADO trials, respectively. Significantly larger improvements in St George’s Respiratory Questionnaire and transition dyspnoea index focal scores were observed and a greater proportion of patients were responders to therapy (based on minimum clinically important differences in St George’s Respiratory Questionnaire and transition dyspnoea index) with tiotropium + olodaterol compared to either monotherapy or to placebo. Tiotropium + olodaterol 5/5 µg significantly reduced night-time rescue medication usage.

Results from four in-depth studies show that a combined inhaler is very effective for treatment of moderate to severe chronic lung disease. Alleviating the symptoms of chronic obstructive pulmonary disease (COPD), particularly sleep disturbance, is crucial to enhancing patients’ quality of life. Gary Ferguson at the Pulmonary Research Institute of Southeast Michigan, together with other scientists across the USA and Germany, analysed data from four large-scale studies to evaluate the efficacy of STIOLTO Respimat, a combination of two bronchodilators—tiotropium, and olodaterol, which tackle airway obstruction and breathlessness, improving long-term lung function. They found that the new drug combination triggered significant improvements in patients’ quality of life and levels of breathlessness. Use of night-time rescue medication in patients on STIOLTO Respimat was considerably reduced. A greater number of patients responded positively to the combined inhaler than to monotherapy.

Smoking and Early COPD as Independent Predictors of Body Composition, Exercise Capacity, and Health Status

The effects of tobacco smoke, mild/moderate COPD disease and their combined effect on health status (HS), body composition (BC), and exercise capacity (EC) impairment are still unclear. We hypothesized that smoking and early COPD have a joint negative influence on these outcomes. We evaluated 32 smokers (smoking history >10 pack/years), 32 mild/moderate COPD (current smokers or former smokers), and 32 never smokers. All individuals underwent medical and smoking status evaluations, pre and post-bronchodilator spirometry, BC [fat-free mass (FFM) and FFM index (FFMI)], EC [six-minute walk distance (6MWD)] and HS [Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36)]. FFM (p = 0.02) and FFMI (p = 0.008) were lower in COPD than never smokers. 6MWT, as a percentage of reference values for the Brazilian population, was lower in COPD and smokers than never smokers (p = 0.01). Smokers showed worse SF-36 score for functional capacity than never smokers (p<0.001). SF-36 score for physical functioning (p<0.001) and role-emotional (p<0.001) were impaired in COPD patients than smokers. SF-36 scores for physical functioning (p<0.001), role-physical (p = 0.01), bodily pain (p = 0.01), vitality (p = 0.04) and role-emotional (p<0.001) were lower in COPD than never smokers. Multiple linear regression analysis showed that both COPD diagnosis and smoking were inversely associated with FFMI, 6MWD and HS. Smoking and early COPD have a joint negative influence on body composition, exercise capacity and health status.

Undiagnosed Obstructive Lung Disease in the United States. Associated Factors and Long-term Mortality

RATIONALE

Understanding factors associated with undiagnosed obstructive lung disease and its impact on mortality could inform the ongoing discussions about benefits and risks of screening and case finding.

OBJECTIVES

To define factors associated with undiagnosed obstructive lung disease and its long-term mortality.

METHODS

Cross-sectional analysis of participants, aged 20 to 79 years, in two National Health and Nutritional Examination Surveys (NHANES), NHANES III (1988-1994) and NHANES 2007-2012, with longitudinal follow-up of NHANES III participants.

MEASUREMENTS AND MAIN RESULTS

We classified participants with spirometry-confirmed obstructive disease, based on the fixed ratio definition (FEV1/FVC < 0.7), as "diagnosed" (physician diagnosis of either asthma or chronic obstructive pulmonary disease), and "undiagnosed" (no recorded physician diagnosis). For the longitudinal analysis of NHANES III participants, mortality was the outcome of interest. We tested the contribution of self-reported health status and comorbidity burden (exposure) to the odds of being undiagnosed using logistic models adjusted for demographics, smoking status, and lung function. We estimated hazard ratios (HRs) for all-cause mortality for diagnosed and undiagnosed subjects participating in NHANES III who had spirometry using Cox- proportional regression analysis. Among those with spirometry-defined obstruction, 71.2% (SE, 1.8) in NHANES III and 72.0% (SE, 1.9) in NHANES 2007-2012 were undiagnosed. In multivariate models, undiagnosed obstructive disease was consistently associated in both surveys with self-reported good/excellent health status, lower comorbidity burden, higher lung function, and being of racial/ethnic minority. Among NHANES III participants (median follow up, 14.5 yr), both undiagnosed (HR, 1.23; 95% confidence interval, 1.08-1.40) and correctly diagnosed participants (HR, 1.74; 95% confidence interval, 1.45-2.09) had higher risk for all-cause mortality than participants without obstruction.

CONCLUSIONS

Undiagnosed obstructive lung disease is common among American adults and remained unchanged over 2 decades. Although undiagnosed subjects appear healthier than those with a diagnosis, their risk of death was increased compared with subjects without obstruction. These findings need to be considered when judging the implications of case-finding programs for obstructive lung disease.

Exacerbations, health services utilization, and costs in commercially-insured COPD patients treated with nebulized long-acting β2-agonists

OBJECTIVE

This retrospective cohort study compared exacerbations, health services utilization, and costs among chronic obstructive pulmonary disease (COPD) patients who received nebulized arformoterol or nebulized formoterol therapy.

METHODS

Using PharMetrics Plus health plan claims, 417 nebulized long-acting β2-agonist (LABA) users meeting the study inclusion criteria were identified: had ≥2 fills of nebulized arformoterol or nebulized formoterol from January 1, 2009, to December 31, 2011, adhered to using their index drug ≥60% of the days during 1 year post-index, were ≥35 years old and continuously enrolled 180 days pre- and 1 year post-index, and did not use a nebulized LABA or have an asthma diagnosis during the pre-index period. Descriptive and multivariate analyses were performed.

RESULTS

A total of 274 nebulized arformoterol users and 143 nebulized formoterol users were identified with comparable demographic characteristics. However, significant differences were observed between the two groups in some clinical characteristics at index including comorbidities and use of antibiotics. At 1 year post-index, a lower proportion of nebulized arformoterol users had ≥1 exacerbation compared to nebulized formoterol users (70.4% vs 80.4%; p = 0.028). Among patients with ≥1 hospital admission, COPD-related costs per inpatient stay were significantly lower for nebulized arformoterol users than nebulized formoterol users (median = $9542 vs $14,025; p = 0.009). After controlling for confounders, nebulized arformoterol users had 19% marginally lower risk of exacerbations than nebulized formoterol users (hazard ratio = 0.81, 95% confidence interval = 0.64-1.03; p < 0.084) and 14.4% marginally lower COPD-related total costs at 1 year post-index (p = 0.062), primarily related to fewer hospital readmissions (7.6% vs 12.2%) and lower average costs per readmission stay (median = $7392 vs $18 081; p = 0.006).

CONCLUSIONS

This study suggests that the choice of nebulized LABA may influence COPD-related exacerbation occurrence and costs. Future studies with larger and more closely matched nebulized arformoterol and nebulized formoterol users are needed to confirm these findings.

Comorbid Influences on Generic Health-Related Quality of Life in COPD: A Systematic Review

Background

Chronic obstructive pulmonary disease (COPD) is a leading cause of mortality and of loss of disability-adjusted life years worldwide. It often is accompanied by the presence of comorbidity.

Objectives

To systematically review the influence of COPD comorbidity on generic health-related quality of life (HRQoL).

Methods

A systematic review approach was used to search the databases Pubmed, Embase and Cochrane Library for studies evaluating the influence of comorbidity on HRQoL in COPD. Identified studies were analyzed according to study characteristics, generic HRQoL measurement instrument, COPD severity and comorbid HRQoL impact. Studies using only non-generic instruments were excluded.

Results

25 studies met the selection criteria. Seven studies utilized the EQ-5D, six studies each used the SF-36 or SF-12. The remaining studies used one of six other instruments each. Utilities were calculated by four EQ-5D studies and one 15D study. Patient populations covered both early and advanced stages of COPD and ranged from populations with mostly stage 1 and 2 to studies with patients classified mainly stage 3 and 4. Evidence was mainly created for cardiovascular disease, depression and anxiety as well as diabetes but also for quantitative comorbid associations. Strong evidence is pointing towards the significant negative association of depression and anxiety on reduced HRQoL in COPD patients. While all studies found the occurrence of specific comorbidities to decrease HRQoL in COPD patients, the orders of magnitude diverged. Due to different patient populations, different measurement tools and different concomitant diseases the study heterogeneity was high.

Conclusions

Facilitating multimorbid intervention guidance, instead of applying a parsimony based single disease paradigm, should constitute an important goal for improving HRQoL of COPD patients in research and in clinical practice.