Incidence of utilization- and symptom-defined COPD exacerbations in hospital- and population-recruited patients

Effectiveness of a 24-hour access outpatient clinic for patients with chronic conditions in hospital outpatient follow-up: a registry-based controlled cohort study of healthcare utilisation and mortality

Objective

To evaluate the effectiveness of a 24-hour telephone access outpatient clinic (24-hour access clinic) in terms of healthcare utilisation and mortality in patients with five chronic conditions (chronic obstructive pulmonary disease, atrial fibrillation/flutter, congestive heart failure, inflammatory bowel disease and chronic liver disease).

Methods and analysis

This was a registry-based controlled cohort study. The 24-hour access clinic was established at Silkeborg Regional Hospital in Central Denmark Region. The five other regional hospitals served as comparison hospitals. The 24-hour access clinic allowed patients with five chronic conditions with ongoing hospital outpatient follow-up to call the hospital outpatient clinic in case of an exacerbation. Outcomes were use of hospital admissions, length of stay (LOS), outpatient visits, contacts to general practice and all-cause mortality during 18 months of follow-up.

Results

The study included 992 the 24-hour access patients and 3878 usual care patients. For the five conditions combined, the 24 hours access patients had fewer all-cause admissions (incidence rate ratio (IRR) 0.81, 95% Cl 0.71 to 0.92), general practice out-of-hours contacts (IRR 0.81, 95% C 0.71 to .92) and shorter LOS (IRR 0.71, 95% CI 0.57 to 0.88). The rate of all-cause outpatient visits tended to be higher (IRR 1.07, 95% CI 0.99 to 1.15). General practice daytime contacts were similar between the groups, and there was no significant difference in mortality.

Conclusions

The results suggest that a 24-hour telephone access clinic may lead to enhanced integration of care measured as unplanned acute care substituted with planned outpatient care.

Towards precision in defining COPD exacerbations

COPD is the most prevalent chronic respiratory disease worldwide and a major cause of disability and death. Acute exacerbations of COPD remain a key feature of the disease in many patients and research assessing interventions to prevent and treat them requires a robust definition with high sensitivity and specificity. To date, no such definition exists, and multiple different definitions are used in clinical studies depending on the research question. The strengths and weaknesses of current definitions are discussed in the context of evolving knowledge and different settings in which studies are undertaken. Whether identification and recording of exacerbations remains essentially clinical, or can be identified with a dependable biomarker, it should be sensitive and adaptable to context while retaining clarity and facilitating data collection. This is essential to progress a better understanding of the pathophysiology and phenotypic expression of exacerbations to reduce their impact and personal burden for patients.

Predicting Re-Exacerbation Timing and Understanding Prolonged Exacerbations: An Analysis of Patients with COPD in the ECLIPSE Cohort

PURPOSE

Understanding risk factors for an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is important for optimizing patient care. We re-analyzed data from the Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints (ECLIPSE) study (NCT00292552) to identify factors predictive of re-exacerbations and associated with prolonged AECOPDs.

METHODS

Patients with COPD from ECLIPSE with moderate/severe AECOPDs were included. The end of the first exacerbation was the index date. Timing of re-exacerbation risk was assessed in patients with 180 days' post-index-date follow-up data. Factors predictive of early (1-90 days) vs late (91-180 days) vs no re-exacerbation were identified using a multivariable partial-proportional-odds-predictive model. Explanatory logistic-regression modeling identified factors associated with prolonged AECOPDs.

RESULTS

Of the 1,554 eligible patients from ECLIPSE, 1,420 had 180 days' follow-up data: more patients experienced early (30.9%) than late (18.7%) re-exacerbations; 50.4% had no re-exacerbation within 180 days. Lower post-bronchodilator FEV1 (P=0.0019), a higher number of moderate/severe exacerbations on/before index date (P<0.0001), higher St. George's Respiratory Questionnaire total score (P=0.0036), and season of index exacerbation (autumn vs winter, P=0.00164) were identified as predictors of early (vs late/none) re-exacerbation risk within 180 days. Similarly, these were all predictors of any (vs none) re-exacerbation risk within 180 days. Median moderate/severe AECOPD duration was 12 days; 22.7% of patients experienced a prolonged AECOPD. The odds of experiencing a prolonged AECOPD were greater for severe vs moderate AECOPDs (adjusted odds ratio=1.917, P=0.002) and lower for spring vs winter AECOPDs (adjusted odds ratio=0.578, P=0.017).

CONCLUSION

Prior exacerbation history, reduced lung function, poorer respiratory-related quality-of-life (greater disease burden), and season may help identify patients who will re-exacerbate within 90 days of an AECOPD. Severe AECOPDs and winter AECOPDs are likely to be prolonged and may require close monitoring.

Blood Eosinophil and Risk of Exacerbation in Chronic Obstructive Pulmonary Disease Patients: A Retrospective Cohort Analysis

Purpose

Blood eosinophil is a readily available biomarker to reflect the eosinophilic inflammation in chronic obstructive pulmonary disease (COPD) patients, yet its association with exacerbation is inconclusive. It is uncertain which measurement, eosinophil percentage or absolute eosinophil count, should be used and what is the optimal cutoff for exacerbation prediction.

Patients and Methods

A total of 247 COPD patients were included in this retrospective cohort study. Blood eosinophil during stable disease state, baseline demographics, and clinical characteristics in 12 months after the index complete blood count (CBC) were recorded. Exacerbation frequencies were compared between patients with high and low blood eosinophil percentage using 2% as cut-off. Logistic regression and receiver operating characteristics (ROC) curve analyses were conducted.

Results

Patients with blood eosinophil ≥2% were associated with more frequent exacerbations than patients with eosinophil <2% in the 12 months after the index CBC (mean exacerbation 1.07 vs 0.34, p < 0.001). Higher blood eosinophil percentage conferred a higher risk of exacerbation. Adjusted odds ratio for exacerbation in 12 months after the index CBC for blood eosinophil ≥2% was 2.98 (95% confidence interval = 1.42–6.25). The area under the ROC curve of eosinophil percentage was significantly higher than that of absolute eosinophil count (0.678 vs 0.640, p = 0.010). The optimal cutoff of blood eosinophil percentage for exacerbation prediction was 2.8%.

Conclusion

Blood eosinophilia was associated with higher exacerbation risk in COPD patients. Further studies are required to elucidate the mechanism of eosinophilic inflammation in COPD and determine the optimal treatment strategy to reduce exacerbations.

The Identification and Cost of Acute Chronic Obstructive Pulmonary Disease Exacerbations in a United States Population Healthcare Claims Database

Almost half of chronic obstructive pulmonary disease (COPD) exacerbations are estimated to be inaccurately reported by patients, inconsistently recorded in medical records, or not measured due to coding errors inherent to administrative claims. This retrospective observational study aimed to develop an algorithm capable of detecting acute COPD exacerbations (AECOPD) in healthcare claims and estimate costs associated with AECOPD over a 12-month period. Commercial and Medicare Advantage healthcare plan members (≥40 years old) with evidence of COPD were identified from US healthcare-claims database. To refine the algorithm detecting AECOPD in claims data, sensitivity and positive-predictive value calculations were performed to compare AECOPD identification in healthcare claims versus medical charts. Analyses were also performed to examine total exacerbation-related costs for events identified with the new claims algorithm plus events missed. The final algorithm had a sensitivity of 84.9%, with a positive-predictive value of 67.5%. Medical records were abstracted for 402 patients. In the overall sample of healthcare claims (n = 243,998), the algorithm detected ≥1 AECOPD event in 61.3% of patients. The mean cost per patient during an AECOPD episode, identified by the final algorithm, was USD 6,760 (n = 301), with an incremental average cost of USD 607 (n = 122) to 'unobserved' episodes (not reported in claims data) among the chart sample. After multivariate modeling, predicted yearly exacerbation costs translated to USD 1.12 billion per 100,000 patients (USD 12,000 per patient), with 35.76 million associated with unobserved exacerbations. While the final algorithm warrants further validation and study, these findings highlight unobserved AECOPD and their economic burden.

Helmet-based noninvasive ventilation for acute exacerbation of chronic obstructive pulmonary disease: A case report

BACKGROUND

Noninvasive ventilation (NIV) reduces intubation rates, mortalities, and lengths of hospital and intensive care unit stays in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). Helmet-based NIV is better tolerated than oronasal mask-based ventilation, and thus, allows NIV to be conducted for prolonged periods at higher pressures with minimal air leaks.

CASE SUMMARY

A 73-year-old man with a previous diagnosis of COPD stage 4 was admitted to our medical intensive care unit with chief complaints of cough, sputum, and dyspnea of several days’ duration. For 10 mo, he had been on oxygen at home by day and had used an oronasal mask-based NIV at night. At intensive care unit admission, he breathed using respiratory accessory muscles. Hypercapnia and signs of infection were detected, and infiltration was observed in the right lower lung field by chest radiography. Thus, we diagnosed AECOPD by community-acquired pneumonia. After admission, respiratory distress steadily deteriorated and invasive mechanical ventilation became necessary. However, the patient refused this option, and thus, we selected helmet-based NIV as a salvage treatment. After 3 d of helmet-based NIV, his consciousness level and hypercapnia recovered to his pre-hospitalization level.

CONCLUSION

Helmet-based NIV could be considered as a salvage treatment when AECOPD patients refuse invasive mechanical ventilation and oronasal mask-based NIV is ineffective.

Comparison of patient-reported outcomes during acute exacerbations of chronic obstructive pulmonary disease

Introduction

The aim of this study was to investigate which patient-reported outcome measure was the best during the recovery phase from severe exacerbation of chronic obstructive pulmonary disease (COPD).

Methods

The Exacerbations of Chronic Pulmonary Disease Tool (EXACT), the COPD Assessment Test (CAT), the St George’s Respiratory Questionnaire (SGRQ), the Dyspnoea-12 (D-12) and the Hyland Scale (global scale) were recorded every week for the first month and at 2 and 3 months in 33 hospitalised subjects with acute exacerbation of COPD (AECOPD).

Results

On the day of admission (day 1), the internal consistency of the EXACT total score was high (Cronbach’s alpha coefficient=0.89). The EXACT total, CAT, SGRQ total and Hyland Scale scores obtained on day 1 appeared to be normally distributed. Neither floor nor ceiling effects were observed for the EXACT total and SGRQ total scores. The EXACT total score improved from 50.5±12.4 to 32.5±14.3, and the CAT score also improved from 24.4±8.5 to 13.5±8.4 during the first 2 weeks, and the effect sizes (ES) of the EXACT total and CAT score were −1.40 and −1.36, respectively. The SGRQ, Hyland Scale and D-12 were less responsive, with ES of −0.59, 0.96 and −0.90, respectively.

Discussion

The EXACT total and CAT scores are shown to be more responsive measures during the recovery phase from severe exacerbation. Considering the conceptual framework, it is recommended that the EXACT total score may be the best measure during the recovery phase from AECOPD. The reasons for the outstanding responsiveness of the CAT are still unknown.

Acute exacerbation of COPD during pulmonary rehabilitation: outcomes and risk prediction

Purpose

This study was performed to examine acute exacerbation of COPD (AECOPD) during pulmonary rehabilitation (PR) and the usefulness of multidimensional indices (MIs) to predict AECOPD at enrolment in PR.

Patients and methods

A 4-week PR program (PRP) was implemented for 125 consecutive patients with COPD. At baseline and PRP completion, we recorded the FEV₁, 6-minute walk test, peak work rate at cardiopulmonary testing, modified Medical Research Council score, and COPD Assessment Test (CAT) score. The risk of AECOPDs at baseline was assessed using the body mass index, airway obstruction, dyspnea, Exercise capacity (BODE), dyspnea, obstruction, smoking, exacerbation (DOSE), and score to predict short-term risk of COPD exacerbations (SCOPEX) MIs.

Results

Thirty-two episodes of AECOPD occurred. The COPD status was worse in patients with than without AECOPD at baseline (lower FEV₁, 6-minute walk test, and peak work rate; higher modified Medical Research Council and CAT scores). The sensitivities of the BODE, DOSE, and SCOPEX MIs to predict the occurrence of AECOPD during PRP were 78.1%, 21.9%, and 84.4%, and the specificities were 73.6%, 87.1%, and 51.6%, respectively.

Conclusion

The BODE and SCOPEX MIs help to predict the exacerbation risk during PR.

'Exacerbation-free time' to assess the impact of exacerbations in patients with chronic obstructive pulmonary disease (COPD): a prospective observational study

COPD exacerbations are commonly quantified as rate per year. However, the total amount of time a patient suffers from exacerbations may be stronger related to his or her disease burden than just counting exacerbation episodes. In this study, we examined the relationship between exacerbation frequency and exacerbation-free time, and their associations with baseline characteristics and health-related quality of life. A total of 166 COPD patients reported symptom changes during 12 months. Symptom-defined exacerbation episodes were correlated to the number of exacerbation-free weeks per year. Analysis of covariance was used to examine the effects of baseline characteristics on annual exacerbation frequency and exacerbation-free weeks, Spearman’s rank correlations to examine associations between the two methods to express exacerbations and the Chronic Respiratory Questionnaire (CRQ). The correlation between exacerbation frequency and exacerbation-free weeks was −0.71 (p < 0.001). However, among frequent exacerbators (i.e., ≥3 exacerbations/year, n = 113) the correlation was weak (r = −0.25; p < 0.01). Smokers had less exacerbation-free weeks than non-smokers (β = −5.709, p < 0.05). More exacerbation-free weeks were related to better CRQ Total (r = 0.22, p < 0.05), Mastery (r = 0.22, p < 0.05), and Fatigue (r = 0.23, p < 0.05) scores, whereas no significant associations were found between exacerbation frequency and CRQ scores. In COPD patients with frequent exacerbations, there is substantial variation in exacerbation-free time. Exacerbation-free time may better reflect the burden of exacerbations in patients with COPD than exacerbation frequency does.

Time spent exacerbation-free may provide a stronger indication of disease burden than exacerbation frequency for patients with chronic lung disease. Exacerbations in chronic obstructive pulmonary disease (COPD) are marked by a sudden decline in lung function, potential hospitalisation and a need to increase medication. Exacerbation frequency is used as a marker in COPD management, but this does not consider the duration of exacerbations or the impact this has on patients’ lives. Lonneke Boer at Radboud University Medical Center, the Netherlands, and co-workers questioned 166 patients every two weeks for a year about their experiences of exacerbation duration and frequency. There was substantial variation in exacerbation-free time between patients, with smokers most likely to suffer longer periods of poorer health. Exacerbation-free time was better correlated with health-related quality of life than exacerbation frequency.