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Singh D, Litewka D, Páramo R, Rendon A, Sayiner A, Tanni SE, Acharya S, Aggarwal B, Ismaila AS, Sharma R, Daley-Yates P. DElaying Disease Progression In COPD with Early Initiation of Dual Bronchodilator or Triple Inhaled PharmacoTherapy (DEPICT): A Predictive Modelling Approach. Adv Ther 2023; 40:4282-4297. [PMID: 37382864 PMCID: PMC10499693 DOI: 10.1007/s12325-023-02583-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 06/09/2023] [Indexed: 06/30/2023]
Abstract
INTRODUCTION Clinical studies demonstrate an accelerated decline in lung function in patients with moderate chronic obstructive pulmonary disease (COPD) (Global Initiative for Chronic Obstructive Lung Disease [GOLD] grade 2) versus severe and very severe COPD (GOLD grades 3 and 4). This predictive modelling study assessed the impact of initiating pharmacotherapy earlier versus later on long-term disease progression in COPD. METHODS The modelling approach used data on decline in forced expiratory volume in 1 s (FEV1) extracted from published studies to develop a longitudinal non-parametric superposition model of lung function decline with progressive impact of exacerbations from 0 per year to 3 per year and no ongoing pharmacotherapy. The model simulated decline in FEV1 and annual exacerbation rates from age 40 to 75 years in COPD with initiation of long-acting anti-muscarinic antagonist (LAMA)/long-acting beta2-agonist (LABA) (umeclidinium (UMEC)/vilanterol (VI)) or triple (inhaled corticosteroid (ICS)/LAMA/LABA; fluticasone furoate (FF)/UMEC/VI) therapy at 40, 55 or 65 years of age. RESULTS Model-predicted decline in FEV1 showed that, compared with 'no ongoing' therapy, initiation of triple or LAMA/LABA therapy at age 40, 55 or 65 years preserved an additional 469.7 mL or 236.0 mL, 327.5 mL or 203.3 mL, or 213.5 mL or 137.5 mL of lung function, respectively, by the age of 75. The corresponding average annual exacerbation rates were reduced from 1.57 to 0.91, 1.06 or 1.23 with triple therapy or to 1.2, 1.26 and 1.4 with LAMA/LABA therapy when initiated at 40, 55 or 65 years of age, respectively. CONCLUSIONS This modelling study suggests that earlier initiation of LAMA/LABA or triple therapy may have positive benefits in slowing disease progression in patients with COPD. Greater benefits were demonstrated with early initiation therapy with triple versus LAMA/LABA.
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Affiliation(s)
- Dave Singh
- Centre for Respiratory Medicine and Allergy, Institute of Inflammation and Repair, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Manchester University NHS Foundation Trust, Manchester, UK
| | - Diego Litewka
- Pulmonology Unit, Hospital General de Agudos Dr. J. A. Fernández, Buenos Aires, Argentina
| | | | - Adrian Rendon
- Universidad Autónoma de Nuevo León, Servicio de Neumología, CIPTIR, Monterrey, NL, México
| | - Abdullah Sayiner
- Department of Chest Diseases, Ege University Faculty of Medicine, İzmir, Turkey
| | - Suzana E Tanni
- Department of Botucatu Medical School, Universidade Estadual Paulista, São Paulo, Brazil
| | | | | | - Afisi S Ismaila
- Value Evidence and Outcomes, GSK, Collegeville, PA, USA
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | | | - Peter Daley-Yates
- Clinical Pharmacology and Experimental Medicine, GSK, Brentford, London, UK.
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Heerema J, Hug S, Bear N, Hill K. Characterising hospitalisation risk for chronic obstructive pulmonary disease exacerbations: Bedside and outpatient clinic assessments of easily measured variables. Chron Respir Dis 2023; 20:14799731231211852. [PMID: 37934787 PMCID: PMC10631319 DOI: 10.1177/14799731231211852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 10/15/2023] [Indexed: 11/09/2023] Open
Abstract
OBJECTIVE To identify the characteristics of people with chronic obstructive pulmonary disease (COPD) who require hospitalisation for exacerbations. METHODS People with COPD were recruited either during hospitalisation or from out-patient respiratory medicine clinics. Hospital admissions were tracked throughout the 5-months recruitment period. For participants who were admitted, hospital readmissions were tracked for at least 30 days following discharge. Participants were grouped as either needing; (i) no hospital admission during the study period (no admission; ø-A), (ii) one or more hospital admissions during the study period but no readmission within 30 days of discharge (no rapid readmission; ø-RR) or (iii) one or more hospital admissions with a readmission within 30 days of discharge (rapid readmission; RR). RESULTS Compared with the ø-A group (n=211), factors that independently increased the risk of ø-RR (n=146) and/or RR (n=57) group membership were being aged >60 years, identifying as an Indigenous person (relative risk ratio, 95% confidence interval 7.8 [1.8 to 34.0]) and the use of a support person or community service for activities of daily living (1.5 [1.0 to 2.4]. A body mass index ≥25 kg/m2 was protective. CONCLUSIONS Variables recorded at the bedside or in clinic provided information on hospitalisation risk.
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Affiliation(s)
- Joshua Heerema
- Physiotherapy Department, Sir Charles Gairdner Hospital, Nedlands, Australia
| | - Sarah Hug
- Curtin School of Allied Health, Curtin University, Perth, Australia
- Physiotherapy Department, Royal Perth Hospital, Perth, Australia
| | - Natasha Bear
- Institute of Health Sciences, Notre Dame University, Perth, Australia
| | - Kylie Hill
- Curtin School of Allied Health, Curtin University, Perth, Australia
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Ouaalaya EH, Falque L, Dupis JM, Sabatini M, Bernady A, Nguyen L, Ozier A, Nocent-Ejnaini C, Le Guillou F, Molimard M, Zysman M, Raherison-Semjen C. Susceptibility to frequent exacerbation in COPD patients: Impact of the exacerbations history, vaccinations and comorbidities? Respir Med 2020; 169:106018. [PMID: 32442114 DOI: 10.1016/j.rmed.2020.106018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 05/01/2020] [Accepted: 05/08/2020] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Exacerbations are key events in the natural history of COPD, but our understanding of their longitudinal determinants remains unclear. We used data from a large observational study to test the hypothesis that vaccination status and comorbidities could be associated with the occurrence of exacerbations profile. METHODS Diagnosed COPD patients have been included by their pulmonologists, with up to 3 years of follow-up. Data were analyzed using the KmL method designed to cluster longitudinal data and receiver operating characteristic curve analysis to determine the best threshold to allocate patients to identified clusters. RESULTS 932 COPD patients were included since January 2014, 446 patients (65.68% males, 35.59% current smokers) were followed over a period of 3 years with complete data. 239(28.15%) patients reported two or more exacerbations in the year before enrolment (frequent exacerbations). Among them 142(16.68%) also had frequent exacerbations in the first year of the study, and 69(8.10%) who remained frequent exacerbators in the second year. Based on our hypothesis, we were able to determine four phenotypes: A (infrequent), B (frequent in underweight patients), C (transient), and D (frequent in obese patients). Frequent exacerbators had more airflow limitation and symptoms. Irrespective of cut-offs set to define the optimal number of clusters, a history of exacerbations OR: 3.72[2.53-5.49], presence of anxiety OR: 2.03[1.24-3.31] and absence of the annual influenza vaccination OR: 1.97[1.20-3.24] remained associated with the frequent exacerbator phenotypes. CONCLUSIONS The most important determinants of frequent exacerbations are a history of exacerbations, anxiety and unvaccinated against influenza.
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Affiliation(s)
- El Hassane Ouaalaya
- Bordeaux University, INSERM, Bordeaux Population Health Research Center, team: EPICENE, UMR1219, Bordeaux, France.
| | | | | | | | | | | | | | | | | | - Mathieu Molimard
- Bordeaux University, INSERM, Bordeaux Population Health Research Center, team Pharmaco-epidemiology, UMR 1219, Bordeaux, France
| | - Maéva Zysman
- Bordeaux University, INSERM, Cardiothoracic Research Center of Bordeaux, team: 2, UMR1045, Bordeaux, France
| | - Chantal Raherison-Semjen
- Bordeaux University, INSERM, Bordeaux Population Health Research Center, team: EPICENE, UMR1219, Bordeaux, France; CHU de Bordeaux, Pole Cardiothoracique, Respiratory Diseases Department, Bordeaux, France
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Cui Y, Dai Z, Luo L, Chen P, Chen Y. Classification and treatment of chronic obstructive pulmonary disease outpatients in China according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017: comparison with GOLD 2014. J Thorac Dis 2019; 11:1303-1315. [PMID: 31179072 DOI: 10.21037/jtd.2019.03.99] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background In 2017, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) proposed new classification criteria for patients with chronic obstructive pulmonary disease (COPD), which categorizes them into groups A-D based on risk of exacerbations and symptoms. The impact of the 2017 revisions on categorization and subsequent drug selection has been insufficiently studied in China. Methods This observational, multicenter, cross-sectional study recruited patients attending the outpatient clinics of 12 tertiary hospitals in China between April 2016 and July 2018. Patients were classified according to the GOLD 2014 and 2017 classification criteria and profiled based on categorization, demographics, clinical characteristics, and treatment regimens. Results In total, 1,278 COPD patients [mean age (±SD), 62.4±8.4 years; body mass index (BMI), 22.3±3.4 kg/m2] were included. According to the GOLD 2014 and 2017 classification criteria, the distribution in groups A-D was 58 (4.5%), 288 (22.5%), 28 (2.2%), 904 (70.7%) and 71 (5.6%), 573 (44.8%), 15 (1.2%), 619 (48.4%), respectively. Overall, 32% of patients in groups C-D were reclassified to groups A-B. Based on both GOLD 2014 and 2017, low BMI and education level were independent risk factors for high risk of exacerbation (i.e., being in groups C-D) (P<0.05). The patients who were reclassified from group D to B were younger and had fewer symptoms than those who remained in group D. The most frequently prescribed regimen was triple inhaled treatment (39.4%). Inhaled corticosteroids (ICS) were prescribed across all groups, and 205 (71.9%) of the 285 patients who were reclassified from group D to B were treated with ICS. Conclusions GOLD 2017 reclassified COPD patients to low-risk groups. The risk of exacerbation increased with decreased BMI or education levels. Overtreatment was observed in many patients, and physicians should reexamine treatment patterns for patients reclassified into low-risk groups.
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Affiliation(s)
- Yanan Cui
- Department of Respiratory Medicine, the Second Xiangya Hospital of Central South University, Changsha 410000, China
| | - Zhongshang Dai
- Department of Respiratory Medicine, the Second Xiangya Hospital of Central South University, Changsha 410000, China
| | - Lijuan Luo
- Department of Respiratory Medicine, the Second Xiangya Hospital of Central South University, Changsha 410000, China
| | - Ping Chen
- Department of Respiratory Medicine, the Second Xiangya Hospital of Central South University, Changsha 410000, China
| | - Yan Chen
- Department of Respiratory Medicine, the Second Xiangya Hospital of Central South University, Changsha 410000, China
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Stanford RH, Lau MS, Li Y, Stemkowski S. External Validation of a COPD Risk Measure in a Commercial and Medicare Population: The COPD Treatment Ratio. J Manag Care Spec Pharm 2019; 25:58-69. [PMID: 30589629 PMCID: PMC10397827 DOI: 10.18553/jmcp.2019.25.1.058] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) exacerbations can accelerate disease progression and lead to higher health care costs. To improve patient survival and reduce cost, risk assessment measures should be developed to identify patients at risk for exacerbations and prevent future exacerbations. OBJECTIVES To (a) externally validate the COPD treatment ratio (CTR) as a measure of COPD exacerbation risk based on predictive models previously tested and (b) assess the measure's capability to assess risk using only pharmacy claims for use in Medicare Part D programs. METHODS This was a retrospective observational study conducted using the Humana research datasets. Separate assessments were performed using pharmacy-only models that excluded risk factors derived from medical claims. Patients were aged ≥ 40 years, with ≥ 1 inpatient hospitalization or ≥ 2 physician's office, emergency department, or urgent care visits with a COPD diagnosis. Using logistic regression models, risk factors (age, exacerbation history, COPD and concomitant medication use, and comorbidities) were assessed during the baseline period (year 1) and were used to predict the risk of exacerbation during year 2. Continuous and dichotomized CTRs were analyzed. A cut-point of 0.3 was initially used for dichotomizing CTR, and subsequently receiver operating characteristics (ROC) analysis was used to determine the optimal cut-point for CTR. RESULTS A total of 92,496 patients were identified, the majority of which (96.2%) were Medicare members with a mean age of 69 years. During the baseline period, 14.0% and 11.2% of patients had ≥ 1 moderate or severe exacerbation, respectively. Overall, the CTR performed well in predicting future COPD exacerbations, especially severe exacerbations. ROC analysis suggested that 0.7 was the optimal cut-point for dichotomizing CTR. Patients with a CTR ≥ 0.7 had a 7.9% (OR = 0.921; 95% CI = 0.852-0.995) lower risk of a severe exacerbation, compared with those with a CTR < 0.7. Stronger effects were seen in pharmacy-only models, with patients 17% less likely to experience a severe exacerbation with a CTR ≥ 0.7 compared with patients with a CTR < 0.7. CONCLUSIONS This study validated the use of CTR as a modifiable measure of risk of COPD exacerbation in a large commercial and Medicare population and remained a robust predictor when pharmacy-only claims data were available. A CTR of ≥ 0.7 may be a useful target to help reduce the risk of severe exacerbations, and its use by payer or quality organizations has the potential to improve COPD management. DISCLOSURES This study was funded by GlaxoSmithKline (GSK; study number HO-15-16651). GSK had a role in the study design, collection, analysis, and interpretation of data and in the writing of the study report but did not place any restrictions on access to the data or on the statements made in the manuscript. The authors were in full editorial control of publication target journal and content and conclusions, accepted full responsibility for final approval of a manuscript describing this GSK-sponsored research, and had final responsibility for the decision to submit for publication. Stanford and Lau are employees of GSK and hold GSK stocks/shares. Li and Stemkowski are employees of Comprehensive Health Insights, which was contracted to conduct the study but did not receive funding for manuscript development. This manuscript was presented in part at the American Thoracic Society 2017 International Conference; May 19-24, 2017; Washington, DC.
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Affiliation(s)
| | | | - Yong Li
- Comprehensive Health Insights, Humana, Louisville, Kentucky
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Validation of a New Risk Measure for Chronic Obstructive Pulmonary Disease Exacerbation Using Health Insurance Claims Data. Ann Am Thorac Soc 2018; 13:1067-75. [PMID: 27070274 DOI: 10.1513/annalsats.201508-493oc] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Current chronic obstructive pulmonary disease (COPD) exacerbation risk prediction models are based on clinical data not easily accessible to national quality-of-care organizations and payers. Models developed from data sources available to these organizations are needed. OBJECTIVES This study aimed to validate a risk measure constructed using pharmacy claims in patients with COPD. Administrative claims data were used to construct a risk model to test and validate the ratio of controller (maintenance) medications to total COPD medications (CTR) as an independent risk measure for COPD exacerbations. The ability of the CTR to predict the risk of COPD exacerbations was also assessed. METHODS This was a retrospective study using health insurance claims data from the Truven MarketScan database (2006-2011), whereby exacerbation risk factors of patients with COPD were observed over a 12-month period and exacerbations monitored in the following year. Exacerbations were defined as moderate (emergency department or outpatient treatment with oral corticosteroid dispensings within 7 d) or severe (hospital admission) on the basis of diagnosis codes. Models were developed and validated using split-sample data from the MarketScan database and further validated using the Reliant Medical Group database. The performance of prediction models was evaluated using C-statistics. MEASUREMENTS AND MAIN RESULTS A total of 258,668 patients with COPD from the MarketScan database were included. A CTR of greater than or equal to 0.3 was significantly associated with a reduced risk for any (adjusted odds ratio [OR], 0.91; 95% confidence interval [CI], 0.85-0.97); moderate (OR, 0.93; 95% CI, 0.87-1.00), or severe (OR, 0.87; 95% CI, 0.80-0.95) exacerbation. The CTR, at a ratio of greater than or equal to 0.3, was predictive in various subpopulations, including those without a history of asthma and those with or without a history of moderate/severe exacerbations. The C-statistics ranged from 0.750 to 0.761 for the development set and 0.714 to 0.761 in the validation sets, indicating the CTR performed well in predicting exacerbation risk. CONCLUSIONS The ratio of controller to total medications dispensed for COPD is a measure that can easily be calculated using only pharmacy claims data. A CTR of greater than or equal to 0.3 can potentially be used as a quality-of-care measurement for prevention of exacerbations.
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Defining the "Frequent Exacerbator" Phenotype in COPD: A Hypothesis-Free Approach. Chest 2017; 153:1106-1115. [PMID: 29054347 DOI: 10.1016/j.chest.2017.10.009] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Revised: 08/31/2017] [Accepted: 10/02/2017] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The COPD "frequent exacerbator" phenotype is usually defined by at least two treated exacerbations per year and is associated with a huge impact on patient health. However, existence of this phenotype and corresponding thresholds still need to be formally confirmed by statistical methods analyzing exacerbation profiles with no specific a priori hypothesis. The aim of this study was to confirm the existence of the frequent exacerbator phenotype with an innovative unbiased statistical analysis of prospectively recorded exacerbations. METHODS Data from patients with COPD from the French cohort in Exacerbations of COPD Patients (EXACO) were analyzed using the KmL method designed to cluster longitudinal data and receiver operating characteristic (ROC) curve analysis to determine the best threshold to allocate patients to identified clusters. Univariate and multivariate analyses were performed to study characteristics associated with different clusters. RESULTS Two clusters of patients were identified based on exacerbation frequency over time, with 2.89 exacerbations per year on average in the first cluster (n = 348) and 0.71 on average in the second cluster (n = 116). The best threshold to distinguish these clusters was two moderate to severe exacerbations per year. Frequent exacerbators had more airflow limitation, symptoms, and health-related quality of life impairment. A simple clinical score was derived to help identify patients at risk of exacerbations. CONCLUSIONS These analyses confirmed the existence and clinical relevance of a frequent exacerbator subgroup of patients with COPD and the currently used threshold to define this phenotype.
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Mirza S, Benzo R. Chronic Obstructive Pulmonary Disease Phenotypes: Implications for Care. Mayo Clin Proc 2017; 92:1104-1112. [PMID: 28688465 PMCID: PMC5587116 DOI: 10.1016/j.mayocp.2017.03.020] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 03/27/2017] [Accepted: 03/28/2017] [Indexed: 11/23/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) phenotyping can help define clusters of patients with common characteristics that relate to clinically meaningful outcomes. In this review, we describe 7 clinically meaningful COPD phenotypes that can be identified by primary care physicians as well as specialists and that have specific management and prognostic implications: (1) asthma-COPD overlap phenotype, (2) frequent exacerbator phenotype, (3) upper lobe-predominant emphysema phenotype, (4) rapid decliner phenotype, (5) comorbid COPD phenotype, (6) physical frailty phenotype, and (7) emotional frailty phenotype.
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Affiliation(s)
- Shireen Mirza
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Roberto Benzo
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN.
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Marsh B, Drake MG. Outpatient Management for Acute Exacerbations of Obstructive Lung Diseases. Med Clin North Am 2017; 101:537-551. [PMID: 28372712 DOI: 10.1016/j.mcna.2016.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Primary care providers tasked with treating acute exacerbations of asthma and chronic obstructive pulmonary disease must be able to recognize exacerbation of symptoms and triage patients based on exacerbation severity to the appropriate level of care. Early treatment with bronchodilators and corticosteroids should be followed by repeated assessments of treatment efficacy. Primary care providers should also provide symptom-guided action plans to empower patients to manage their disease.
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Affiliation(s)
- Brenda Marsh
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA
| | - Matthew G Drake
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA.
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Faes K, De Frène V, Cohen J, Annemans L. Resource Use and Health Care Costs of COPD Patients at the End of Life: A Systematic Review. J Pain Symptom Manage 2016; 52:588-599. [PMID: 27401511 DOI: 10.1016/j.jpainsymman.2016.04.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Revised: 03/21/2016] [Accepted: 04/29/2016] [Indexed: 10/21/2022]
Abstract
CONTEXT Patients with chronic obstructive pulmonary disease (COPD) in their final months of life potentially place a high burden on health care systems. Concrete knowledge about resources used and costs incurred by those patients at the end of life is crucial for policymakers. OBJECTIVES The aim of this systematic review was to describe the resources used and costs incurred by patients with COPD at the end of life. METHODS We performed a comprehensive literature search in MEDLINE, Web of Science, and EconLit. We screened 886 abstracts and subsequently reviewed 80 full-text articles. Inclusion criteria were at least one type of resource use and/or cost outcome reported in adults diagnosed with COPD during an end-of-life period. Subsequently, we performed quality appraisal consistent with the ISPOR checklist for retrospective database studies and accomplished comprehensive data extraction. RESULTS Ten articles fulfilled the inclusion criteria. Three, five, and two studies described European, North American, and Asian health care settings, respectively. All studies had a retrospective design and were published between 2006 and 2015. We observed a very variable resource use, an increased number of hospitalizations, intensive care unit stays, primary care consultations and medication prescriptions, as well as a lack of utilization of formal palliative care services in end-of-life COPD patients. Specific cost items were not well described. CONCLUSION The high use of health care resources in COPD patients in the final months of life suggests a focus on prolonging life and a tendency toward aggressive care. Limiting potentially inappropriate care and improving the quality of end-of-life care in advanced COPD are, therefore, important public health challenges.
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Affiliation(s)
- Kristof Faes
- Department of Public Health, Ghent University, Ghent, Belgium.
| | - Veerle De Frène
- Department of Public Health, Ghent University, Ghent, Belgium
| | - Joachim Cohen
- Department of Family Medicine & Chronic Care, End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
| | - Lieven Annemans
- Department of Public Health, Ghent University, Ghent, Belgium
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Dretzke J, Moore D, Dave C, Mukherjee R, Price MJ, Bayliss S, Wu X, Jordan RE, Turner AM. The effect of domiciliary noninvasive ventilation on clinical outcomes in stable and recently hospitalized patients with COPD: a systematic review and meta-analysis. Int J Chron Obstruct Pulmon Dis 2016; 11:2269-2286. [PMID: 27698560 PMCID: PMC5034919 DOI: 10.2147/copd.s104238] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Introduction Noninvasive ventilation (NIV) improves survival among patients with hypercapnic respiratory failure in hospital, but evidence for its use in domiciliary settings is limited. A patient’s underlying risk of having an exacerbation may affect any potential benefit that can be gained from domiciliary NIV. This is the first comprehensive systematic review to stratify patients based on a proxy for exacerbation risk: patients in a stable state and those immediately post-exacerbation hospitalization. Methods A systematic review of nonrandomized and randomized controlled trials (RCTs) was undertaken in order to compare the relative effectiveness of different types of domiciliary NIV and usual care on hospital admissions, mortality, and health-related quality of life. Standard systematic review methods were used for identifying studies (until September 2014), quality appraisal, and synthesis. Data were presented in forest plots and pooled where appropriate using random-effects meta-analysis. Results Thirty-one studies were included. For stable patients, there was no evidence of a survival benefit from NIV (relative risk [RR] 0.88 [0.55, 1.43], I2=60.4%, n=7 RCTs), but there was a possible trend toward fewer hospitalizations (weighted mean difference −0.46 [−1.02, 0.09], I2=59.2%, n=5 RCTs) and improved health-related quality of life. For posthospital patients, survival benefit could not be demonstrated within the three RCTs (RR 0.89 [0.53, 1.49], I2=25.1%), although there was evidence of benefit from four non-RCTs (RR 0.45 [0.32, 0.65], I2=0%). Effects on hospitalizations were inconsistent. Post hoc analyses suggested that NIV-related improvements in hypercapnia were associated with reduced hospital admissions across both populations. Little data were available comparing different types of NIV. Conclusion The effectiveness of domiciliary NIV remains uncertain; however, some patients may benefit. Further research is required to identify these patients and to explore the relevance of improvements in hypercapnia in influencing clinical outcomes. Optimum time points for commencing domiciliary NIV and equipment settings need to be established.
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Affiliation(s)
- Janine Dretzke
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston
| | - David Moore
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston
| | - Chirag Dave
- Heart of England NHS Foundation Trust, Heartlands Hospital
| | | | - Malcolm J Price
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston
| | - Sue Bayliss
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston
| | - Xiaoying Wu
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston
| | - Rachel E Jordan
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston
| | - Alice M Turner
- Heart of England NHS Foundation Trust, Heartlands Hospital; Queen Elizabeth Hospital Research Laboratories, University of Birmingham, Edgbaston, Birmingham, UK
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Margüello MS, Garrastazu R, Ruiz-Nuñez M, Helguera JM, Arenal S, Bonnardeux C, León C, Miravitlles M, García-Rivero JL. Independent effect of prior exacerbation frequency and disease severity on the risk of future exacerbations of COPD: a retrospective cohort study. NPJ Prim Care Respir Med 2016; 26:16046. [PMID: 27604472 PMCID: PMC5015428 DOI: 10.1038/npjpcrm.2016.46] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 05/17/2016] [Accepted: 06/06/2016] [Indexed: 01/26/2023] Open
Abstract
Few studies have researched the independent effect of COPD severity on the risk of future exacerbations adjusted by previous exacerbation frequency. We aimed to analyse the independent effect of COPD severity on the risk of exacerbations in the following year, and whether this effect was stronger or not than the effect of a previous history of exacerbations. We conducted a retrospective population-based cohort study including 900 patients with confirmed COPD. Exacerbation frequency was observed for the previous year and for the following year. Patients were defined as ‘Frequent Exacerbator’ (FE) phenotype if they suffered ⩾2 exacerbations in a year, and were categorised according to the severity of COPD (GOLD Grades 1–4). Odds ratios (ORs) were estimated by logistic regression adjusting for age, gender, smoking status, severity of COPD and being FE in the previous year. The main predictor of being FE among all grades of COPD severity was a history of frequent exacerbations in the previous year: adjusted OR 4.97; 95% confidence interval (CI) (3.54–6.97). COPD severity was associated with a higher risk of being FE: Crude OR GOLD Grade 4 3.86; 95% CI (1.50–9.93). However, this association diminished after adjusting for being FE in the previous year: adjusted OR 2.08; 95% CI (0.75–5.82). Our results support that a history of frequent exacerbations in the previous year is the most important independent predictor of exacerbations in the following year, also among the most severe COPD patients. Severity of COPD would be associated with a higher risk of exacerbations, but this effect would be partly determined by the exacerbations suffered in the previous year.
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Affiliation(s)
| | - Roberto Garrastazu
- Centro de Salud de Gama, Servicio Cántabro de Salud, Bárcena de Cicero, Spain
| | - Mario Ruiz-Nuñez
- Centro de Salud de Liérganes, Servicio Cántabro de Salud, Miera, Spain
| | | | - Sandra Arenal
- Centro de Salud de Suances, Servicio Cántabro de Salud, Suances, Spain
| | - Cristina Bonnardeux
- Centro de Salud Campoo-Los Valles, Servicio Cántabro de Salud, Mataporquera, Spain
| | - Carlos León
- Centro de Salud de Suances, Servicio Cántabro de Salud, Suances, Spain
| | - Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d'Hebron; CIBER of respiratory diseases (CIBERESP), Barcelona, Spain
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Santibáñez M, Garrastazu R, Ruiz-Nuñez M, Helguera JM, Arenal S, Bonnardeux C, León C, García-Rivero JL. Predictors of Hospitalized Exacerbations and Mortality in Chronic Obstructive Pulmonary Disease. PLoS One 2016; 11:e0158727. [PMID: 27362765 PMCID: PMC4928940 DOI: 10.1371/journal.pone.0158727] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 06/21/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND AIM Exacerbations of chronic obstructive pulmonary disease (COPD) carry significant consequences for patients and are responsible for considerable health-care costs-particularly if hospitalization is required. Despite the importance of hospitalized exacerbations, relatively little is known about their determinants. This study aimed to analyze predictors of hospitalized exacerbations and mortality in COPD patients. METHODS This was a retrospective population-based cohort study. We selected 900 patients with confirmed COPD aged ≥35 years by simple random sampling among all COPD patients in Cantabria (northern Spain) on December 31, 2011. We defined moderate exacerbations as events that led a care provider to prescribe antibiotics or corticosteroids and severe exacerbations as exacerbations requiring hospital admission. We observed exacerbation frequency over the previous year (2011) and following year (2012). We categorized patients according to COPD severity based on forced expiratory volume in 1 second (Global Initiative for Chronic Obstructive Lung Disease [GOLD] grades 1-4). We estimated the odds ratios (ORs) by logistic regression, adjusting for age, sex, smoking status, COPD severity, and frequent exacerbator phenotype the previous year. RESULTS Of the patients, 16.4% had ≥1 severe exacerbations, varying from 9.3% in mild GOLD grade 1 to 44% in very severe COPD patients. A history of at least two prior severe exacerbations was positively associated with new severe exacerbations (adjusted OR, 6.73; 95% confidence interval [CI], 3.53-12.83) and mortality (adjusted OR, 7.63; 95%CI, 3.41-17.05). Older age and several comorbidities, such as heart failure and diabetes, were similarly associated. CONCLUSIONS Hospitalized exacerbations occurred with all grades of airflow limitation. A history of severe exacerbations was associated with new hospitalized exacerbations and mortality.
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Affiliation(s)
- Miguel Santibáñez
- Preventive Medicine and Public Health Area, Universidad de Cantabria-IDIVAL, Santander, Cantabria, Spain
- * E-mail:
| | - Roberto Garrastazu
- Centro de Salud de Gama, Servicio Cántabro de Salud, Bárcena de Cicero, Cantabria, Spain
| | - Mario Ruiz-Nuñez
- Centro de Salud de Liérganes, Servicio Cántabro de Salud, Miera, Cantabria, Spain
| | - Jose Manuel Helguera
- Centro de Salud Bajo Asón, Servicio Cántabro de Salud, Cantabria, Ampuero, Spain
| | - Sandra Arenal
- Centro de Salud de Suances, Servicio Cántabro de Salud, Suances, Cantabria, Spain
| | - Cristina Bonnardeux
- Centro de Salud Campoo-Los Valles, Servicio Cántabro de Salud, Mataporquera, Cantabria, Spain
| | - Carlos León
- Centro de Salud de Suances, Servicio Cántabro de Salud, Suances, Cantabria, Spain
| | - Juan Luis García-Rivero
- Pneumology Department, Hospital de Laredo, Servicio Cántabro de Salud, Laredo, Cantabria, Spain
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Gumus A, Haziroglu M, Gunes Y. Association of serum magnesium levels with frequency of acute exacerbations in chronic obstructive pulmonary disease: a prospective study. Pulm Med 2014; 2014:329476. [PMID: 25485151 PMCID: PMC4251077 DOI: 10.1155/2014/329476] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 11/03/2014] [Accepted: 11/04/2014] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The course of chronic obstructive pulmonary disease (COPD) is accompanied by acute exacerbations. The purpose of this study is to determine the association of serum magnesium level with acute exacerbations in COPD (COPD-AE). MATERIALS AND METHODS Eighty-nine patients hospitalized with COPD-AE were included. Hemogram, biochemical tests, and arterial blood gases were analyzed. Pulmonary function tests were performed in the stable period after discharge. Patients were followed up at 3 monthly periods for one year. RESULTS Mean age of the patients was 70.4 ± 7.8 (range 47-90) years. Mean number of COPD-AE during follow-up was 4.0 ± 3.6 (range 0-15). On Spearman correlation analysis there were significant negative correlations between number of COPD-AE and predicted FEV1% (P = 0.001), total protein (P = 0.024), globulin (P = 0.001), creatinine (P = 0.001), and uric acid levels (P = 0.036). There were also significant positive correlations between number of COPD-AE and serum magnesium level (P < 0.001) and platelet count (P = 0.043). According to linear regression analysis predicted FEV1% (P = 0.011), serum magnesium (P < 0.001), and globulin (P = 0.006) levels were independent predictors of number of COPD-AE. CONCLUSIONS In this small prospective observational study we found that serum magnesium level during exacerbation period was the most significant predictor of frequency of COPD-AE.
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Affiliation(s)
- Aziz Gumus
- Department of Pulmonary Medicine, Recep Tayyip Erdogan University, 53000 Rize, Turkey
| | - Muge Haziroglu
- Department of Pulmonary Medicine, Recep Tayyip Erdogan University, 53000 Rize, Turkey
| | - Yilmaz Gunes
- Cardiology Department, Hisar Intercontinental Hospital, 34375 Istanbul, Turkey
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