Non-adherence to COPD medications and its association with adverse events: A longitudinal population based cohort study of older adults

OBJECTIVE

To determine the association between non-adherence to long term chronic obstructive pulmonary disease (COPD) medications and COPD related emergency department (ED) visits and hospitalizations in patients with incident COPD, utilizing time varying measures of adherence as well as accounting for time-varying confounding impacted by prior adherence.

STUDY DESIGN AND SETTING

We conducted a population-based retrospective cohort study between 2007-2017 among individuals aged 66 years and older with incident COPD using multiple linked administrative health databases from the province of Ontario, Canada. Adherence to COPD medications was measured using time varying proportion of days covered based on insurance claims for medications dispensed at community pharmacies. The parametric g-formula was used to assess the association between time-varying adherence (in the last 90-days) to COPD medications and risk of COPD related hospitalizations and ED visits while accounting for time varying confounding by COPD severity.

RESULTS

Overall, 60,251 individuals with incident COPD were included; mean age was 76 (SD 7) and 59% were male. Mean adherence over the entire follow-up was 23% (SD 0.3). There were 7248 (12%) COPD related ED visits (2.8 events per 100 person years [PY]) and 9188 (15%) COPD related hospitalizations (3.5 events per 100 PY). Compared to those with 0% 90-day adherence, those with adherence between 1-33% had a 19% decreased risk of COPD related ED visits (adjusted risk ratio[aRR]:0.81, 95% confidence interval [CI]:0.78-0.83), those with adherence between 34%-67% had a 18% decreased risk (aRR: 0.82, 95% CI: 0.77-0.85) while those with 68%-100% 90-day adherence had a 63% increased risk of COPD related ED visits (aRR: 1.63, 95% CI: 1.47-1.78). Nearly identical results were obtained for COPD specific hospitalizations.

CONCLUSION

After accounting for time varying confounding by COPD severity, the highest time varying 90-days adherence was associated with an increased risk of both COPD related ED visits and hospitalizations compared to the lowest adherence categories. Differences in COPD severity between adherence categories, perception of need for medication management in the higher adherence categories, and potential residual confounding makes it difficult to disentangle the independent effects of adherence from the severity of the condition itself.

Analysis of the quality of e-Consultations in chronic obstructive pulmonary disease

INTRODUCTION

The quality of e-Consultations in the COPD is unknown. The objectives of this study were (i) to evaluate the quality of referrals; (ii) to define the characteristics of patients referred from Primary Care (PC) to the Unit of Pulmonology; and (iii) to describe differences between accepted and rejected patients.

METHODS

A retrospective, observational study of e-Consultations requested by PC for suspected COPD throughout 2022. To quantify the quality of the e-Consultations, an arbitrary scale of 12 variables (score 0-10) was created.

RESULTS

In total, 384 e-Consultations were reviewed, of which 167 (43.5 %) resulted in a face-to-face visit, and 217 (56.5 %) were rejected. No differences were observed between the two types of patients, except for confirmations of diagnostic suspicion of COPD [significantly higher in accepted patients (p = 0.042)]; physical examination data of rejected patients (more data provided; p = 0.015); and lung function (significantly better in rejected patients). The mean quality of referrals was acceptable (5.6 ± 2.1 score): 121 (31.3 %) had insufficient quality; 118 (30.5 %) acceptable; 75 (19.4 %) good, and 30 (7.8 %) excellent. Quality was low in half of the variables analyzed (6/12); acceptable in 3, and good in another 3. The capacity of resolution of referrals was good (one e-Consultation) in 199 requests (66.1 %); deficient (two e-Consultations) in 72 (23.9 %), and poor (≥3 e-Consultations) in 30 (10 %). Overdiagnosis was 40.2 % (86/214 e-Consultations). The risk could be classified in 247 patients (64.3 %; 135 low-risk; 90 high-risk).

CONCLUSIONS

When adequate information is provided, e-Consultations help identify different levels of severity. However, the quality and capacity of resolution of referrals were suboptimal, with a high percentage of overdiagnoses.

Should we screen aging physicians for cognitive decline?

OBJECTIVES

To synthesize evidence relevant for informed decisions concerning cognitive testing of older physicians.

METHODS

Relevant literature was systematically searched in Medline, EMBASE, PsycInfo, and ERIC, with key findings abstracted and synthesized.

RESULTS

Cognitive abilities of physicians may decline in an age range where they are still practicing. Physician competence and clinical performance may also decline with age. Cognitive scores are lower in physicians referred for assessment because of competency or performance concerns. Many physicians do not accurately self-assess and continue to practice despite declining quality of care; however, perceived cognitive decline, although not an accurate indicator of ability, may accelerate physicians' decision to retire. Physicians are reluctant to report colleagues' cognitive problems. Several issues should be considered in implementing cognitive screening. Most cognitive assessment tools lack normative data for physicians. Scientific evidence linking cognitive test results with physician performance is limited. There is no known level of cognitive decline at which a doctor is no longer fit to practice. Finally, relevant domains of cognitive ability vary across medical specialties.

CONCLUSION

Physician cognitive decline may impact clinical performance. If cognitive assessment of older physicians is to be implemented, it should consider challenges of cognitive test result interpretation.

2023 Canadian Thoracic Society Guideline on Pharmacotherapy in Patients With Stable COPD

Chronic obstructive pulmonary disease patient care must include confirming a diagnosis with postbronchodilator spirometry. Because of the clinical heterogeneity and the reality that airflow obstruction assessed by spirometry only partially reflects disease severity, a thorough clinical evaluation of the patient should include assessment of symptom burden and risk of exacerbations that permits the implementation of evidence-informed pharmacologic and nonpharmacologic interventions. This guideline provides recommendations from a comprehensive systematic review with a meta-analysis and expert-informed clinical remarks to optimize maintenance pharmacologic therapy for individuals with stable COPD, and a revised and practical treatment pathway based on new evidence since the 2019 update of the Canadian Thoracic Society (CTS) Guideline. The key clinical questions were developed using the Patients/Population (P), Intervention(s) (I), Comparison/Comparator (C), and Outcome (O) model for three questions that focuses on the outcomes of symptoms (dyspnea)/health status, acute exacerbations, and mortality. The evidence from this systematic review and meta-analysis leads to the recommendation that all symptomatic patients with spirometry-confirmed COPD should receive long-acting bronchodilator maintenance therapy. Those with moderate to severe dyspnea (modified Medical Research Council ≥ 2) and/or impaired health status (COPD Assessment Test ≥ 10) and a low risk of exacerbations should receive combination therapy with a long-acting muscarinic antagonist/long-acting ẞ2-agonist (LAMA/LABA). For those with a moderate/severe dyspnea and/or impaired health status and a high risk of exacerbations should be prescribed triple combination therapy (LAMA/LABA/inhaled corticosteroids) azithromycin, roflumilast or N-acetylcysteine is recommended for specific populations; a recommendation against the use of theophylline, maintenance systemic oral corticosteroids such as prednisone and inhaled corticosteroid monotherapy is made for all COPD patients.

Reductions in inhaler greenhouse gas emissions by addressing care gaps in asthma and chronic obstructive pulmonary disease: an analysis

INTRODUCTION

Climate change from greenhouse gas (GHG) emissions represents one of the greatest public health threats of our time. Inhalers (and particularly metred-dose inhalers (MDIs)) used for asthma and chronic obstructive pulmonary disease (COPD), constitute an important source of GHGs. In this analysis, we aimed to estimate the carbon footprint impact of improving three distinct aspects of respiratory care that drive avoidable inhaler use in Canada.

METHODS

We used published data to estimate the prevalence of misdiagnosed disease, existing inhaler use patterns, medication class distributions, inhaler type distributions and GHGs associated with inhaler actuations, to quantify annual GHG emissions in Canada: (1) attributable to asthma and COPD misdiagnosis; (2) attributable to overuse of rescue inhalers due to suboptimally controlled symptoms; and (3) avoidable by switching 25% of patients with existing asthma and COPD to an otherwise comparable therapeutic option with a lower GHG footprint.

RESULTS

We identified the following avoidable annual GHG emissions: (1) ~49 100 GHG metric tons (MTs) due to misdiagnosed disease; (2) ~143 000 GHG MTs due to suboptimal symptom control; and (3) ~262 100 GHG MTs due to preferential prescription of strategies featuring MDIs over lower-GHG-emitting options (when 25% of patients are switched to lower GHG alternatives). Combined, the GHG emission reductions from bridging these gaps would be the equivalent to taking ~101 100 vehicles off the roads each year.

CONCLUSIONS

Our analysis shows that the carbon savings from addressing misdiagnosis and suboptimal disease control are comparable to those achievable by switching one in four patients to lower GHG-emitting therapeutic strategies. Behaviour change strategies required to achieve and sustain delivery of evidence-based real-world care are complex, but the added identified incentive of carbon footprint reduction may in itself prove to be a powerful motivator for change among providers and patients. This additional benefit can be leveraged in future behaviour change interventions.

Complexity in clinical diagnoses of acute exacerbation of chronic obstructive pulmonary disease

BACKGROUND

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a clinical syndrome with various causes. It is not uncommon that COPD patients presenting with dyspnea have multiple causes for their symptoms including AECOPD, pneumonia, or congestive heart failure occurring concurrently.

METHODS

To identify clinical, radiographic, and laboratory characteristics that might help distinguish AECOPD from another dominant disease in patients with a history of COPD, we conducted a retrospective cohort study of hospitalized patients with admitting diagnosis of AECOPD who were screened for a prospective randomized controlled trial from Sep 2016 to Mar 2018. Clinical characteristics, course in hospital, and final diagnosis at discharge were reviewed and adjudicated by two authors. The final diagnosis of each patient was determined based on the synthesis of all presenting signs and symptoms, imaging, and laboratory results. We adhered to AECOPD diagnosis definitions based on the GOLD guidelines. Univariate and multivariate analyses were performed to identify any associated features of AECOPD with and without other acute processes contributing to dyspnea.

RESULTS

Three hundred fifteen hospitalized patients with admitting diagnosis of AECOPD were included. Mean age was 72.5 (SD 10.6) years. Two thirds (65.4%) had spirometry defined COPD. The most common presenting symptom was dyspnea (96.5%), followed by cough (67.9%), and increased sputum (57.5%). One hundred and eighty (57.1%) had a final diagnosis of AECOPD alone whereas 87 (27.6%) had AECOPD with other conditions and 48 (15.2%) did not have AECOPD after adjudication. Increased sputum purulence (OR 3.35, 95%CI 1.68-6.69) and elevated venous pCO2 (OR 1.04, 95%CI 1.01 - 1.07) were associated with a diagnosis of AECOPD but these were not associated with AECOPD alone without concomitant conditions. Radiographic evidence of pleural effusion (OR 0.26, 95%CI 0.12 - 0.58) was negatively associated with AECOPD with or without other conditions while radiographic evidence of pulmonary edema (OR 0.31; 95%CI 0.11 - 0.91) and lobar pneumonia (OR 0.13, 95%CI 0.07 - 0.25) suggested against the diagnosis of AECOPD alone.

CONCLUSION

The study highlighted the complexity and difficulty of AECOPD diagnosis. A more specific clinical tool to diagnose AECOPD is needed.

Barriers and Enablers to Objective Testing for Asthma and COPD in Primary Care: A Systematic Review Using the Theoretical Domains Framework

BACKGROUND

Although guidelines have long recommended objective pulmonary function testing to diagnose asthma and chronic obstructive lung disease (COPD), many primary care patients receive a clinical diagnosis of asthma or COPD without objective testing. This often leads to unnecessary treatment with associated incremental costs and side-effects, and delays actual diagnosis.

RESEARCH QUESTION

What are the barriers and enablers to lung function testing for asthma and/or COPD in primary care?

STUDY DESIGN AND METHODS

We searched the literature for qualitative and quantitative studies reporting barriers and/or enablers to in-office or out-of-office lung function testing for diagnosing asthma and/or COPD, in primary care. Two reviewers independently screened abstracts and full texts; assessed methodological quality using the Mixed Methods Appraisal Tool; and extracted data from included studies. Identified barriers and enablers were categorized using the Theoretical Domains Framework (TDF), applying a pre-established coding manual.

RESULTS

We identified 7988 unique articles, reviewed 336 full-text articles, and included 18 studies in this systematic review. Of these 18, 12 were quantitative, 3 were qualitative, and 3 used mixed methods. All 18 addressed in-office testing and 11 also addressed out-of-office testing. Barriers and enablers overlapped for asthma and COPD, and in- and out-of-office settings. We identified more reported barriers (e.g. lack of knowledge of the usefulness of spirometry) than enablers (e.g. skills for performing reliable spirometry). Barriers mapped to 9 (of a possible 14) TDF domains (for both in- and out-of-office settings). Enablers mapped to three domains for in-office testing and five domains for out-of-office testing.

INTERPRETATION

Barriers to objective testing for airways disease in primary care are complex and span many theoretical domains. Correspondingly, a successful intervention must leverage multiple behaviour change techniques. A theory-based, multifaceted intervention to address underuse of diagnostic testing for asthma or COPD should now be developed and tested.

Multi-channel lung sounds intelligent diagnosis of chronic obstructive pulmonary disease

Background

Chronic obstructive pulmonary disease (COPD) is a chronic respiratory disease that seriously threatens people’s health, with high morbidity and mortality worldwide. At present, the clinical diagnosis methods of COPD are time-consuming, invasive, and radioactive. Therefore, it is urgent to develop a non-invasive and rapid COPD severity diagnosis technique suitable for daily screening in clinical practice.

Results

This study established an effective model for the preliminary diagnosis of COPD severity using lung sounds with few channels. Firstly, the time-frequency-energy features of 12 channels lung sounds were extracted by Hilbert–Huang transform. And then, channels and features were screened by the reliefF algorithm. Finally, the feature sets were input into a support vector machine to diagnose COPD severity, and the performance with Bayes, decision tree, and deep belief network was compared. Experimental results show that high classification performance using only 4-channel lung sounds of L1, L2, L3, and L4 channels can be achieved by the proposed model. The accuracy, sensitivity, and specificity of mild COPD and moderate + severe COPD were 89.13%, 87.72%, and 91.01%, respectively. The classification performance rates of moderate COPD and severe COPD were 94.26%, 97.32%, and 89.93% for accuracy, sensitivity, and specificity, respectively.

Conclusion

This model provides a standardized evaluation with high classification performance rates, which can assist doctors to complete the preliminary diagnosis of COPD severity immediately, and has important clinical significance.

Comorbid Anxiety and Depression, Though Underdiagnosed, Are Not Associated with High Rates of Low-Value Care in Patients with Chronic Obstructive Pulmonary Disease

Rationale: Patients with chronic obstructive pulmonary disease (COPD) and anxiety or depression experience more symptoms and exacerbations than patients without these comorbidities. Failure to provide beneficial COPD therapies to appropriate patients (underuse) and provision of potentially harmful therapies to patients without an appropriate indication (overuse) could contribute to respiratory symptoms and exacerbations. Anxiety and depression are known to affect the provision of health services for other comorbid conditions; therefore, underuse or overuse of therapies may explain the increased risk of severe symptoms among these patients.Objectives: To determine whether diagnosed anxiety and depression, as well as significant anxiety and depression symptoms, are associated with underuse and overuse of appropriate COPD therapies.Methods: We analyzed data from a multicenter prospective cohort study of 2,376 participants (smokers and control subjects) enrolled between 2010 and 2015. We identified two subgroups of participants, one at risk for inhaled corticosteroid (ICS) overuse and one at risk for long-acting bronchodilator (LABD) underuse based on the 2011 Global Initiative for Chronic Obstructive Lung Disease statement. Our primary outcomes were self-reported overuse and underuse. Our primary exposures of interest were self-reported anxiety and depression and significant anxiety and depression symptoms. We adopted a propensity-score method with inverse probability of treatment weighting adjusting for differences in prevalence of confounders and performed inverse probability of treatment weighting logistic regression to evaluate all associations between the exposures and outcomes.Results: Among the 1,783 study participants with COPD confirmed by spirometry, 667 (37.4%) did not have an indication for ICS use, whereas 985 (55.2%) had an indication for LABD use. Twenty-five percent (n = 167) of patients reported ICS use, and 72% (n = 709) denied LABD use in each subgroup, respectively. Neither self-reported anxiety and depression nor significant anxiety and depression symptoms were associated with overuse or underuse. At least 50% of patients in both subgroups with significant symptoms of anxiety or depression did not report a preexisting mental health diagnosis.Conclusions: Underuse of LABDs and overuse of ICSs are common but are not associated with comorbid anxiety or depression diagnosis or symptoms. Approximately one-third of individuals with COPD experience anxiety or depression, and most are undiagnosed. There are significant opportunities to improve disease-specific and patient-centered treatment for individuals with COPD.

FACTORS ASSOCIATED WITH NON-RECEIPT OF RECOMMENDED CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) MEDICATIONS: A POPULATION STUDY

BACKGROUND

Chronic obstructive pulmonary disease (COPD) medications reduce exacerbations and improve quality of life. Despite this, some individuals do not receive medications recommended by practise guidelines.

RESEARCH QUESTION

How common is non-receipt of recommended medications among people with COPD and what are factors associated with non-receipt?

STUDY DESIGN AND METHODS

We conducted a population cohort study in Ontario, Canada, a province with universal health care insurance and medication coverage for those aged 65 and older. Health administrative data were used to identify people 66 years of age or older with physician-diagnosed COPD as of 2018 and group them into lower or higher risk for future COPD exacerbation groups. Proportions of patients in each group who did not receive medications recommended by COPD guidelines were determined. Generalized estimating equation modelling was used to determine associations between patient and physician factors and non-receipt of recommended medications.

RESULTS

About 54% and 88% of people with COPD receoved sufficient recommended medications in the low and high risk of exacerbation groups, respectively. Longer duration of COPD, higher comorbidity, dementia, and older physician age were associated with non-receipt of recommended medications in both groups. People who had a co-diagnosis of asthma and who received care by a pulmonologist and spirometry were more likely to receive recommended medication .

INTERPRETATION

COPD medications appear underused by the COPD population and various factors are associated with sub-optimal receipt. Targeting these factors would help improve the care and health of people with COPD.

Breathless and awaiting diagnosis in UK lockdown for COVID-19…We're stuck

During the COVID-19 pandemic, semi-structured interviews were undertaken with 20 adults awaiting a diagnosis for their chronic breathlessness. Three key themes were identified using thematic analysis: (1) de-prioritisation of diagnosis, (2) following UK 'lockdown' guidance for the general population but patients fearful they were more at risk, and (3) the impact of lockdown on coping strategies for managing breathlessness. The existing unpredictable pathway to diagnosis for those with chronic breathlessness has been further interrupted during the COVID-19 pandemic.

Medication Discontinuation in Adults With COPD Discharged From the Hospital: A Population-Based Cohort Study

BACKGROUND

Patients admitted to the hospital with COPD are commonly managed with inhaled short-acting bronchodilators, sometimes in lieu of the long-acting bronchodilators they take as outpatients. If held on admission, these long-acting inhalers should be re-initiated upon discharge; however, health-care transitions sometimes result in unintentional discontinuation.

RESEARCH QUESTION

What is the risk of unintentional discontinuation of long-acting muscarinic antagonist (LAMA) and long-acting beta-agonist and inhaled corticosteroid (LABA-ICS) combination medications following hospital discharge in older adults with COPD?

STUDY DESIGN AND METHODS

A retrospective cohort study was conducted by using health administrative data from 2004 to 2016 from Ontario, Canada. Adults with COPD aged ≥ 66 years who had filled prescriptions for a LAMA or LABA-ICS continuously for ≥ 1 year were included. Log-binomial regression models were used to determine risk of medication discontinuation following hospitalization in each medication cohort.

RESULTS

Of the 27,613 hospitalization discharges included in this study, medications were discontinued 1,466 times. Among 78,953 patients with COPD continuously taking a LAMA or LABA-ICS, those hospitalized had a higher risk of having medications being discontinued than those who remained in the community (adjusted risk ratios of 1.50 [95% CI, 1.34-1.67; P < .001] and 1.62 [95% CI, 1.39, 1.90; P < .001] for LAMA and LABA-ICS, respectively). Crude rates of discontinuation for people taking LAMAs were 5.2% in the hospitalization group and 3.3% in the community group; for people taking LABA-ICS, these rates were 5.5% in the hospitalization group and 3.1% in the community group.

INTERPRETATION

In an observational study of highly compliant patients with COPD, hospitalization was associated with an increased risk of long-acting inhaler discontinuation. These Results suggest a likely larger discontinuation problem among less adherent patients and should be confirmed and quantified in a prospective cohort of patients with COPD and average compliance. Quality improvement efforts should focus on safe transitions and patient medication reconciliation following discharge.

Effectiveness and Safety of Inhaled Corticosteroids in Older Individuals with Chronic Obstructive Pulmonary Disease and/or Asthma. A Population Study

Rationale: Inhaled corticosteroids (ICS) are established medications for the management of both asthma and chronic obstructive pulmonary disease (COPD), two common chronic airway diseases. However, there is still uncertainty with respect to their use in some cases, specifically in older adults with asthma, people with concurrent asthma and COPD, and some people with COPD (given the association of ICS with pneumonia).Objectives: To compare the effectiveness and safety of ICS in older adults with asthma, COPD, or features of both in a real-word setting.Methods: In this retrospective longitudinal population cohort study, individuals 66 years of age or older in Ontario, Canada, who met a validated case definition of physician-diagnosed COPD and/or asthma between 2003 and 2014 were followed until March 2015 through provincial health administrative data. Overlap in COPD and asthma diagnoses was permitted and stratified for in subgroup analyses. The exposure was new receipt of ICS. The primary effectiveness and safety outcomes were hospitalizations for obstructive lung disease (OLD) and hospitalizations for pneumonia, respectively. Propensity scores were used to adjust for confounders.Results: The study included 87,690 individuals with asthma (27% with concurrent COPD) and 150,593 individuals with COPD (25% with concurrent asthma). In terms of effectiveness, controlling for confounders, ICS was associated with fewer hospitalizations for OLD (hazard ratio [HR], 0.84; 95% confidence interval [CI], 0.79-0.88) in subjects with asthma alone, with concurrent COPD attenuating the benefit. A similar association was seen in subjects with COPD and concurrent asthma (HR, 0.88; 95% CI, 0.84-0.92), but not in those with COPD alone, where ICS receipt had little impact on hospitalizations. In terms of safety, ICS receipt was associated with a marginally increased risk of pneumonia hospitalizations in people with COPD and no asthma (HR, 1.03; 95% CI, 1.00-1.06), but not in the other groups.Conclusions: ICS was associated with fewer hospitalizations for OLD in older adults with asthma and concurrent asthma and COPD, but had little impact on OLD and pneumonia hospitalizations in those with COPD alone.

[Lung sounds can be used as an indicator for assessing severity of chronic obstructive pulmonary disease at the initial diagnosis]

OBJECTIVE

To assess the value of pulmonary auscultation for evaluating the severity of chronic obstructive pulmonary disease (COPD) at the initial diagnosis.

METHODS

The patients with newly diagnosed COPD in our hospital between May, 2016 and May, 2019 were enrolled in this study. According to the findings of pulmonary auscultation, the lung sounds were classified into 5 groups: normal breathing sounds, weakened breathing sounds, weakened breathing sounds with wheezing, obviously weakened breathing sounds, and obviously weakened breathing sounds with wheezing. The pulmonary function of the patients was graded according to GOLD guidelines, and the differential diagnosis of COPD from asthmatic asthma COPD overlap (ACO) was made based on the GOLD guidelines and the European Respiratory Criteria.

RESULTS

A total of 1046 newly diagnosed COPD patients were enrolled, including 949 male and 97 female patients with a mean age of 62.6± 8.71. According to the GOLD criteria, 88.1% of the patients were identified to have moderate or above COPD, 50.0% to have severe or above COPD; a further diagnosis of ACO was made in 347 (33.2%) of the patients. ANOVA analysis showed significant differences in disease course, FEV1, FEV1%, FEV1/FVC, FVC, FVC% and mMRC among the 5 auscultation groups (P < 0.001), but FENO did not differ significantly among them (P=0.097). The percentage of patients with wheezing in auscultation was significantly greater in ACO group than in COPD group (P < 0.001). Spearman correlation analysis showed that lung sounds was significantly correlated with disease severity, FEV1, FEV1%, FVC and FVC% of the patients (P < 0.001); Multiple linear regression analysis showed that a longer disease course, a history of smoking and lung sounds were all associated with poorer lung functions and a greater disease severity.

CONCLUSIONS

Lung sounds can be used as an indicator for assessing the severity of COPD at the initial diagnosis.

Population-based case-finding to identify subjects with undiagnosed asthma or COPD

BACKGROUND

∼5-10% of adults may have undiagnosed airflow obstruction. The objective of this study was to develop a population-based case-finding strategy to assess the prevalence of undiagnosed airflow obstruction (asthma or COPD) amongst adults with respiratory symptoms in Canada.

METHODS

Adults without a previous history of asthma, COPD or lung disease were recruited using random digit-dialling and asked if they had symptoms of dyspnoea, cough, sputum or wheeze within the past 6 months. Those who answered affirmatively completed the Asthma Screening Questionnaire (ASQ), COPD-Diagnostic Questionnaire (COPD-DQ) and COPD Assessment Test (CAT). Those with an ASQ score of ≥6 or a COPD-DQ score of ≥20 underwent pre- and post-bronchodilator spirometry to diagnose asthma or COPD.

RESULTS

12 117 individuals were contacted at home and assessed for study eligibility. Of the 1260 eligible individuals, 910 (72%) enrolled and underwent spirometry. Ultimately, 184 subjects (20% of those enrolled) had obstructive lung disease (73 asthma and 111 COPD). Individuals found to have undiagnosed asthma or COPD had more severe respiratory symptoms and impaired quality of life compared with those without airflow obstruction. The ASQ, COPD-DQ, and CAT had ROC areas for predicting undiagnosed asthma or COPD of 0.49, 0.64 and 0.56, respectively. Four descriptive variables (age, BMI, sex and pack-years smoked) produced better receiver operating characteristic (ROC) values than the questionnaires (ROC area=0.68).

CONCLUSION

20% of randomly selected individuals who report respiratory symptoms in Canada have undiagnosed airflow obstruction due to asthma or COPD. Questionnaires could exclude subjects at low risk but lack the ability to accurately find subjects with undiagnosed disease.

Reducing Chronic Obstructive Pulmonary Disease Hospital Readmissions. An Official American Thoracic Society Workshop Report

Chronic obstructive pulmonary disease (COPD) is the third leading cause of hospital readmissions in the United States. The quality of care delivered to patients with COPD is known to be lacking across the care continuum, and may contribute to high rates of readmission. As part of the response to these issues, the Centers for Medicare and Medicaid instituted a penalty for 30-day readmissions as part of their Hospital Readmission Reduction Program in October 2014. At the time the penalty was instated, there was little published evidence on effective hospital-based programs to reduce readmissions after acute exacerbations of COPD. Even now, several years later, few published programs exist, and we continue to lack consistent approaches that lead to improved readmission rates. In addition, there was concern that the penalty would widen health disparities. Despite the dearth of published evidence to reduce readmissions beyond available COPD guidelines, many hospitals across the United States began to develop and implement programs, based on little evidence, due to the financial penalty. We, therefore, assembled a diverse group of clinicians, researchers, payers, and program leaders from across the country to present and discuss approaches that had the greatest potential for success. We drew on expertise from ongoing readmission reduction programs, implementation methodologies, and stakeholder perspectives to develop this Workshop Report on current best practices and models for addressing COPD hospital readmissions.

Cardiovascular Outcomes and All-Cause Mortality in Patients with Obstructive Sleep Apnea and Chronic Obstructive Pulmonary Disease (Overlap Syndrome)

RATIONALE

The combined impact of chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA) on cardiovascular outcomes remains controversial.

OBJECTIVES

We determined whether the combined presence of COPD and severe OSA defined by the apnea-hypopnea index (AHI) or degree of nocturnal hypoxemia is associated with increased hazards of cardiovascular events and mortality.

METHODS

Prospectively collected data from adults with suspected OSA who underwent sleep study between 1994 and 2010 were linked to provincial administrative data to determine a presence of COPD and composite outcome. Exposures of interest were: 1) AHI greater than 30, and 2) 10 or more minutes of sleep time spent with oxygen saturation (Sa_O2) less than 90%. The primary outcome was a composite of hospitalization due to myocardial infarction, stroke, congestive heart failure, cardiac revascularization procedures, or death from any cause. Using Cox regression and controlling for confounders, hazards were compared between four groups: AHI greater than 30 with COPD, AHI greater than 30 without COPD, AHI less than or equal to 30 with COPD, and AHI less than or equal to 30 without COPD (reference). A similar approach was used for the degree of nocturnal hypoxemia. Relative excess risk due to interaction (RERI) was calculated. To adjust for the effect of positive airway pressure treatment, given that information on its acceptance, but not adherence, was available, a separate analysis was conducted only on untreated individuals who never claimed a positive airway pressure device.

RESULTS

Among 10,149 participants, 30% had AHI greater than 30, 25% spent at least 10 minutes of sleep with Sa_O2 less than 90%, and 12% had COPD. Over a median of 9.4 years, 16.4% developed an outcome. In the total sample, a greater hazard of outcome was observed in individuals with COPD who spent at least 10 minutes of sleep with Sa_O2 less than 90% (hazard ratio, 1.91; 95% confidence interval [CI], 1.60 to 2.28) but not with AHI greater than 30; a synergistic effect was found in women (RERI, 1.18; 95% CI, 0.05 to 2.30), but not men (RERI, -0.08; 95% CI, -0.47 to 0.32). The highest hazard of outcome was associated with the co-occurrence of AHI greater than 30 and COPD in untreated individuals (hazard ratio, 2.01; 95% CI, 1.55 to 2.62); a synergistic effect was not found.

CONCLUSIONS

In adults with suspected OSA, the co-occurrence of nocturnal hypoxemia and COPD was associated with an increased hazard of cardiovascular events and mortality with a synergistic effect found only in women.

Influenza Vaccine Effectiveness in Preventing Hospitalizations in Older Patients With Chronic Obstructive Pulmonary Disease

BACKGROUND

Annual influenza immunization is recommended for people with chronic obstructive pulmonary disease (COPD) by all major COPD clinical practice guidelines. We sought to determine the seasonal influenza vaccine effectiveness (VE) against laboratory-confirmed influenza-associated hospitalizations among older adults with COPD.

METHODS

We conducted a test-negative study of influenza VE in community-dwelling older adults with COPD in Ontario, Canada using health administrative data and respiratory specimens collected from patients tested for influenza during the 2010-11 to 2015-16 influenza seasons. Influenza vaccination was ascertained from physician and pharmacist billing claims. Multivariable logistic regression was used to estimate the adjusted odds ratio of influenza vaccination in people with, compared to those without, laboratory-confirmed influenza.

RESULTS

Receipt of seasonal influenza vaccine was associated with an adjusted 22% (95% confidence interval [CI], 15%-27%) reduction in laboratory-confirmed influenza-associated hospitalization. Adjustment for potential misclassification of vaccination status increased this to 43% (95% CI, 35%-52%). Vaccine effectiveness was not found to vary by patient- or influenza-related variables.

CONCLUSIONS

During the studied influenza seasons, influenza vaccination was at least modestly effective in reducing laboratory-confirmed influenza-associated hospitalizations in people with COPD. The imperfect effectiveness emphasizes the need for better influenza vaccines and other preventive strategies.

Longer Duration of Palliative Care in Patients With COPD Is Associated With Death Outside the Hospital

BACKGROUND

Patients with advanced chronic obstructive pulmonary disease (COPD) have a significant symptom burden despite maximal medical therapy, yet few are referred for concomitant palliative care.

OBJECTIVE

To evaluate the utilization and impact of palliative care on the location of death and to identify clinical variables associated with palliative care contact.

DESIGN

Retrospective chart review from 2010 to 2016 at the VA Western New York Healthcare System using ICD-9/10 diagnosis of COPD. Palliative care contact was identified by Z51.5 or stop code 353.

RESULTS

Only 0.5% to 2% of living patients received palliative care, increasing abruptly at death (6%). Lower diffusion capacity for carbon monoxide (DLCO) (greater emphysema) was associated with palliative care contact, independent of comorbid disease burden or age. Initial outpatient contact was associated with a longer duration of palliative care (P = .003) and death in a home-like setting. Outpatient palliative care was associated with more severe airflow obstruction (forced expiratory volume in 1 second, percent predicted [FEV1%]), whereas greater disease exacerbation frequency was associated with inpatient contact. COPD patients not referred to palliative care had a greater comorbid disease burden, similar FEV1%, fewer disease exacerbations, and a greater DLCO.

CONCLUSION

Few patients with COPD received palliative care, similar to national trends. Initial outpatient palliative contact had the longest duration of care and death in the preferred home environment. The extent of emphysema (DLCO reduction) and more frequent disease exacerbations identified in patients were more likely to receive palliative care. Our study begins to define the benefits of palliative care in advanced COPD and confirms underutilization in the years before death, where a prolonged impact on the quality of life may be realized.

Which Physicians Are Taking Care of People With COPD?

BACKGROUND

There is limited knowledge on what proportions of patients with COPD receive ambulatory care from primary care physicians, pulmonologists, or other specialists. We evaluated the types and combinations of physicians who provide ambulatory care to patients with COPD.

METHODS

We conducted a population-based cross-sectional study using health administrative datasets from Ontario, Canada between April 1, 2014 and March 31, 2015. Individuals age 35 years and older with physician-diagnosed COPD were identified, using a previously validated COPD case definition. The primary outcomes were ambulatory visits to primary care physicians, pulmonologists, and all other specialists within a 1-year period.

RESULTS

There were 895,155 individuals identified as having physician-diagnosed COPD. Of those, 56,533 individuals (6.3%) had no ambulatory care visits, 802,327 (89.6%) saw primary care physicians, and 95,782 (10.7%) consulted pulmonologists. By comparison, 736,496 (82.3%) saw other specialists, and 218,997 (24.5%) saw cardiologists. There were 32,473 individuals (3.6%) who underwent COPD-related hospitalizations. Of those in the subcohort with one hospitalization, about 30.0% saw pulmonologists; 43.7% of those who underwent two or more hospitalizations saw pulmonologists, and 9.9% with no hospitalization consulted pulmonologists.

CONCLUSIONS

Primary care physicians play a substantial role in caring for patients with COPD. But only one-half as many patients with COPD saw pulmonologists than cardiologists, suggesting that COPD may receive less specialty care compared with other chronic medical conditions. This information can help inform COPD care strategies to improve COPD care and minimize exacerbations and associated health-care costs. It also suggests a need for more research to provide guidance on when patients with COPD should be referred to pulmonologists.

Concomitant pulmonologist and primary care for chronic obstructive pulmonary disease: a population study

BACKGROUND

Pulmonologists provide quality care, however, their number is not adequate to take care of all the chronic obstructive pulmonary disease (COPD) needs of the population and their services come with a cost. Their optimal role should be defined, ideally based on evidence, to ensure that their abilities are applied most efficiently where needed.

OBJECTIVE

To determine if concomitant pulmonologist and primary care physician care after COPD hospital or emergency department discharge was associated with better health outcomes than primary care services alone.

METHODS

A population cohort study was conducted in Ontario, Canada from 2004 to 2011. All individuals with a COPD hospital or emergency department discharge were included. Patients who visited both a pulmonologist and a primary care physician within 30 days of the index discharge were matched to patients who had visited a primary care physician alone using propensity scores. The composite outcome of death, COPD hospitalization or COPD emergency department visit was compared using proportional hazards regression.

RESULTS

In the propensity score matched sample, 39.7% of patients who received concomitant care and 38.9% who received primary care only died or visited the emergency department visit or hospital for COPD within 1 year (adjusted hazard ratio 1.08, 95% confidence interval 1.00-1.17). The former, however, were more likely to receive diagnostic testing and medications.

CONCLUSION

Patients who received concomitant care after COPD emergency department or hospital discharge did not have better outcomes than those who received primary care alone, however, they did receive more testing and medical management.

Overdiagnosis of COPD in hospitalized patients

Background

The diagnosis of chronic obstructive pulmonary disease (COPD) is usually made based on history and physical exam alone. Symptoms of dyspnea, cough, and wheeze are nonspecific and attributable to a variety of diseases. Confirmatory testing to verify the airflow obstruction is available but rarely used, which may result in substantial misdiagnoses of COPD. The aim of this study is to evaluate the use of confirmatory testing and assess the accuracy of the diagnosis.

Methods

From January 2011 through December 2013, 6,018 patients with COPD as a principal or leading diagnosis were admitted at a community teaching hospital. Of those, only 504 (8.4%) patients had spirometry performed during hospitalization. The studies were reviewed by two board-certified pulmonologists to verify presence of persistent airflow obstruction. Charts of these patients were then examined to determine if the spirometry results had changed the diagnosis or the treatment plan for these patients.

Results

Spirometry confirmed the diagnosis of COPD in 270 patients (69.2%) treated as COPD during their hospitalization. Restrictive lung disease was found to be present in 104 patients (26.6%) and normal in 16 patients (4.2%). Factors predictive of airflow obstruction included smoking status and higher pack-year history. Negative predictive factors included higher body mass index (BMI) and other medical comorbidities. These patients were significantly more likely to be misdiagnosed and mistreated as COPD.

Conclusion

Up to a third of patients diagnosed and treated as COPD in the hospital may be inaccurately diagnosed as COPD based on confirmatory spirometry testing. Factors contributing to the inaccuracy of diagnosis include less smoking history, high BMI, and associated comorbidities.

Outcomes of patients with chronic obstructive pulmonary disease diagnosed with or without pulmonary function testing

BACKGROUND

A small number of people with chronic obstructive pulmonary disease (COPD) receive pulmonary function testing around the time of diagnosis. Because omitting testing increases misdiagnosis, we sought to determine whether health outcomes differed between patients whose COPD was diagnosed with or without pulmonary function testing.

METHODS

We conducted a longitudinal population study of patients with physician-diagnosed COPD from 2005 to 2012 using health administrative data from Ontario, Canada. We assessed whether having pulmonary function testing around the time of diagnosis was associated with the composite outcome of admission to hospital for COPD or all-cause death, using adjusted survival analysis.

RESULTS

Chronic obstructive pulmonary disease was diagnosed in 68 898 patients during the study period; 41.2% of patients received peridiagnostic pulmonary function testing. In adjusted analysis, patients who underwent testing were less likely to die or be admitted to hospital for COPD (adjusted hazard ratio [HR] 0.91, 95% confidence interval [CI] 0.89-0.94) and were more likely to be prescribed an inhaled long-acting bronchodilator than patients who did not undergo testing. Subgroup analysis suggested that the association of testing and outcomes was confined to patients with COPD diagnosed in the ambulatory care setting (adjusted HR 0.80, 95% CI 0.76-0.84).

INTERPRETATION

Confirmation of a COPD diagnosis using pulmonary function testing is associated with a decreased risk of death and admission to hospital for COPD. In ambulatory patients, this effect may be from increased use of appropriate COPD medications. The findings of this study validate current guideline recommendations that encourage pulmonary function testing for diagnosis in all patients with suspected COPD.

Concurrent physician-diagnosed asthma and chronic obstructive pulmonary disease: A population study of prevalence, incidence and mortality

OBJECTIVE

We conducted a population-based cohort study to estimate trends in prevalence, incidence, and mortality of concurrent physician-diagnosed asthma and chronic obstructive pulmonary disease (COPD).

STUDY DESIGN AND SETTING

Two validated health administrative case definitions were used to identify asthma and COPD among all individuals aged 35 years and older living in Ontario, Canada. Annual asthma, COPD, and concurrent asthma and COPD prevalence, incidence, and mortality, standardized for age and sex, were estimated, and compared from 2002 to 2012, using generalized linear models.

RESULTS

Standardized prevalence of concurrent asthma and COPD increased by 10.5%, from 2.9% in 2002 to 3.2% in 2012 overall, but more prominently in women compared to men. Overall, standardized incidence decreased by16%, from 2.5 to 2.1 per 1000 individuals, but increased significantly in young adults. All-cause mortality among patients with concurrent asthma and COPD decreased by 11.2%, from 2.6% to 2.2%. Being diagnosed with both diseases was significantly associated with higher all-cause mortality compared to asthma (OR = 1.56, 95% CI: 1.50-1.58), but not compared to COPD (OR = 0.97, 0.96-0.98), except in young adults aged 35 to 49 years where people with asthma and COPD had higher mortality (OR = 1.21, 1.15-1.27).

CONCLUSIONS

In a large North American population, the burden of concurrent physician-diagnosed asthma and COPD is increasing, particularly in women and young adults.

Novel Interprofessional Mentoring Intervention to Improve Spirometry in Primary Care: Uptake, Feedback, and Effects on Behavioral Intention

INTRODUCTION

Little is known about the nature and effects of mentoring interventions on evidence-based clinician behaviors. We sought to design and evaluate a novel mentorship-based intervention to improve the usage of spirometry in primary care.

METHODS

This was a prospective one-year study of a pragmatic intervention across Canadian primary care sites. We established mentor-mentee pods, each including physician and nurse/allied health mentors and mentees, and enabled communication through a secure online portal; email; telephone; teleconference; videoconference; fax; and/or in person. We measured (1) change in intention to perform spirometry (through a questionnaire based on the theory of planned behavior, administered before and after the intervention); (2) mentoring uptake; and (3) feedback/satisfaction.

RESULTS

Twenty-five of 90 (28%) nurse/allied health and 23/68 (34%) physician mentees consented across seven sites. There were no statistically significant changes in behavioral intention after the intervention. Mentors logged 56.5 hours, with most preferred communication modalities being in person (6/11; 55%) and email (4/11; 36%). Mentees most commonly used email (9/18; 50%), followed by in-person communication (6/18; 33%). Mentees were highly satisfied with the experience, and most (89%) would participate in a similar program again.

DISCUSSION

A mentorship-based intervention can successfully engage physicians, nurses, and allied health practitioners through multiple communication platforms. Email seems to be an important medium for this activity. Such interventions can be highly satisfying and may affect certain constructs underlying mentees' behavioral intentions. Such a program can be replicated across diseases, and future research should measure effects on behavior, patient outcomes, and the sustainability of effects.

Predictors of long-term compensatory response of pulmonary function following major lung resection for non-small cell lung cancer

BACKGROUND AND OBJECTIVE

Long-term pulmonary function which might include compensatory response (CR) significantly influences quality of life of long-term survivor after major lung resection. We investigated long-term pulmonary function after major lung resection.

METHODS

A total of 137 patients who had undergone lobar resection for non-small cell lung cancer (NSCLC) from May 2013 to June 2014 had spirometry at 10-14 months after surgery. Actual post-operative forced expiratory volume in 1 s (FEV₁ ) (FEV_1apo )/predicted post-operative FEV₁ (FEV_1ppo ), actual post-operative forced vital capacity (FVC) (FVC_apo )/predicted post-operative FVC (FVC_ppo ), its relationship with clinicopathological factors and immunohistochemistry for pro-surfactant protein C (pro-SPC), thyroid transcription factor-1 (TTF-1) and vascular endothelial growth factor receptor 2 (VEGFR2) were investigated.

RESULTS

FEV_1apo /FEV_1ppo showed strong correlation with FVC_apo /FVC_ppo (r = 0.628; P < 0.001). We defined greater CR as both FEV_1apo /FEV_1ppo and FVC_apo /FVC_ppo were >120%. Greater CR was significantly associated with decreased smoking index (P < 0.001) and greater resected subsegments (P = 0.037). The never-smoker group revealed significantly greater CR compared with the smoker group in both FEV_1apo /FEV_1ppo (119.9 ± 12.5% vs 107.5 ± 14.2%; P = 0.030) and FVC_apo /FVC_ppo (117.9 ± 9.98% vs 107.2 ± 13.1%; P = 0.046) in case-matched comparison. The expression of pro-SPC, TTF-1 and VEGFR2 in the normal lung parenchyma of greater CR group was significantly higher than those of lesser CR group (P < 0.001 for each). In addition, pro-SPC, TTF-1 and VEGFR2 expressions showed a significant correlation to the degree of CR especially in the smoker group (r = 0.631, 0.705 and 0.732, respectively; P < 0.001 for each).

CONCLUSION

Our data suggest that smokers may develop lesser long-term CR after major lung resection. Decreased expression of pro-SPC, TTF-1 and VEGFR2 may indicate decreased capacity of CR, especially in patients who smoke.

Effects of a 12-month multi-faceted mentoring intervention on knowledge, quality, and usage of spirometry in primary care: a before-and-after study

Background

Asthma is among the most common chronic diseases in adults. International guidelines have emphasized the importance of regular spirometry for asthma control evaluation. However, spirometry use in primary care remains low across jurisdictions. We sought to design and evaluate a knowledge translation intervention to address both the poor quality of spirometry and the underuse of spirometry in primary care.

Methods

We designed a 1-year intervention consisting of initial interactive education and hands-on training followed by unstructured peer expert mentoring (through an online portal, email, telephone, videoconference, fax, and/or in-person). We recruited physician and allied health mentees from across primary care sites in Ontario, Canada. We compared spirometry-related knowledge immediately before and after the 1-year intervention period and the quality of spirometry testing and the usage of spirometry in patients with asthma in the year before and the year of the intervention.

Results

Seven of 10 (70 %) invited sites participated, including 25/90 (28 %) invited allied health mentees and 23/68 (34 %) invited physician mentees. We recruited 7 physician mentors and 4 allied health mentors to form 3 mentor-mentee pods. Spirometry knowledge scores increased from 21.4 +/− 3.1 pre- to 27.3 +/− 3.5 (out of 35) (p < 0.01) post-intervention. Spirometry acceptability and repeatability criteria were met by 59/191 (30.9 %) spirometries and 86/193 (44.6 %) spirometries [odds ratio 1.7 (1.0, 3.0)], in the pre-intervention and intervention periods, respectively. Spirometry was ordered in 75/512 (14.6 %) and 129/336 (38.4 %) respiratory visits (p < 0.01), and in 20/3490 (0.6 %) and 36/2649 (1.4 %) non-respiratory visits (p < 0.01), in the pre-intervention and intervention periods, respectively.

Conclusions

A mentorship-based intervention involving physicians and allied health team members can enhance knowledge, quality, and actual use of spirometry in real world primary care settings. A future controlled study should assess the impact of this intervention on patient outcomes, its cost-effectiveness, and its sustainability.

Electronic supplementary material

The online version of this article (doi:10.1186/s12890-016-0220-6) contains supplementary material, which is available to authorized users.

Factors associated with inadequate diagnosis of COPD: On-Sint cohort analysis

BACKGROUND

The purpose of this study was to evaluate the frequency of inadequate diagnosis and factors predictive of this in patients with chronic obstructive pulmonary disease (COPD) participating in the On-Sint study.

METHODS

The On-Sint cohort was recruited for a multicenter observational study in which 356 physicians (71.6% from primary care) included adult patients who had been diagnosed with COPD. Patients' clinical and functional information since diagnosis and details for the recruiting physicians were collected from patient files and at the inclusion visit. We performed a multivariate analysis to evaluate the influence of these variables on diagnostic inadequacy (absence of postbronchodilator forced expiratory volume in one second/forced vital capacity [FEV1/FVC] <0.70 or, if this value was missing, prebronchodilator FEV1/FVC <0.70).

RESULTS

In total, 1,214 patients were included in the study. The patients had a mean age of 66.4±9.7 years and 78.8% were male. In total, 51.3% of patients did not have an obstructive spirometry performed, and 21.4% had a normal or non-obstructive spirometry pattern. Patient-related factors associated with inadequate diagnosis were: years since diagnosis (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01-1.05), number of exacerbations in the previous year (OR 1.01, 95% CI 1.01-1.02), comorbidities (OR 1.05, 95% CI 1.01-1.015), and obesity (OR 1.06, 95% CI 1.02-1.10 per kg/m(2) of body mass index), while a longer smoking history (OR 0.98, 95% CI 0.97-0.99 for each pack/year) and short-acting or long-acting bronchodilator therapy (OR 0.61, 95% CI 0.44-0.76 and OR 0.46, 95% CI 0.27-0.76, respectively) were inversely related. With regard to physician-related variables, being followed up by primary care physicians (OR 3.0, 95% CI 2.11-4.34) and in rural centers (OR 1.63, 95% CI 1.12-2.38) were positively associated with an inadequate diagnosis, while having regular follow-ups in the most severe cases (OR 0.66, 95% CI 0.46-0.93) and use of quality of life questionnaires (OR 0.55, 95% CI 0.40-0.76) were negatively associated.

CONCLUSION

Diagnosis of COPD was inadequate in half of the patients from the On-Sint cohort. There were multiple factors, both patient-related and physician-related, associated with this misdiagnosis.

Quantifying comorbidity in individuals with COPD: a population study

Chronic obstructive pulmonary disease (COPD) has been associated with many types of comorbidity. We aimed to quantify the real world impact of COPD on lower respiratory tract infection, cardiovascular disease, diabetes, psychiatric disease, musculoskeletal disease and cancer, and their impact on COPD through health services.

A population study using health administrative data from Ontario, Canada, in 2008–2012 was conducted. Absolute and adjusted relative rates of ambulatory care visits, emergency department visits and hospitalisations for the comorbidities of interest in people with and without COPD were determined and compared.

Among 7 241 591 adults, 909 948 (12.6%) had COPD. Over half of all lung cancer, a third of all lower respiratory tract infection and cardiovascular disease, a quarter of all low trauma fracture, and a fifth of all psychiatric, musculoskeletal, non-lung cancer and diabetes ambulatory care visits, emergency department visits and hospitalisations in Ontario were used by people with COPD. Individuals with COPD used about five times more health services for lung cancer, and two times more health services for lower respiratory tract infections and cardiovascular disease than people without COPD.

Individuals with COPD use a disproportionate amount of health services for comorbid disease, placing significant burden on the healthcare system.