Direct and Indirect Costs of Chronic Obstructive Pulmonary Disease in Korea

PM10-bound microplastics and trace metals: A public health insight from the Korean subway and indoor environments

Inhalable airborne microplastics (MPs) presented in indoor and outdoor environments, can deeply penetrate the lungs, potentially triggering inflammation and respiratory illnesses. The present study aims to evaluate human health risks from respirable particulate matter (PM)-bound trace metals and MPs in indoor (SW- subway and IRH- indoor residential houses) and outdoor (OD) environments. This research provides an initial approach to human respiratory tract (HRT) mass depositions of PM10-bound total MPs and nine specific MP types to predict potential human health threats from inhalation exposure. Results indicate that PM-bound trace metals and MPs were around 4 times higher in SW microenvironments compared to OD locations. In IRH, cancer risk (CR) levels were estimated 9 and 4 times higher for PM10 and PM2.5, respectively. Additionally, MP particle depositions per gram of lung cell weight were highest in IRH (23.77), followed by OD and SW. Whereas, lifetime alveoli depositions of MPs were estimated at 13.73 MP/g, which exceeds previously reported respiratory disease fatality cases by 10 to 5 times. Prolonged exposure duration at IRH emerged as a key factor contributing to increased CR and MP lung deposition levels. This research highlights severe lung risks from inhaling PM-bound MPs and metals, offering valuable health insights.

Comparing Costs and Healthcare Resource Utilization (HCRU) Using LAMA versus LABA/ICS at Treatment Initiation for COPD: Findings from CITRUS (Comparing the Incidence of Tiotropium and ICS/LABA in Real-World Use in South Korea) Study

Background

COPD causes substantial economic burden on healthcare. Alternative treatment strategies for COPD can be associated with different costs dependent upon their relative safety and effectiveness. We compared costs and healthcare resource utilization (HCRU) associated with LAMA or LABA/ICS initiation.

Methods

Using the Korean National Health Insurance Service database, we enrolled COPD patients initiating treatment with LAMA or LABA/ICS between January 2005 and April 2015. Propensity score matched individuals were compared on all-cause and COPD-related medical costs and HCRU over a three-year follow-up period.

Results

A total of 2444 patients were enrolled in each treatment group. LAMA group was associated with significantly lower costs than LABA/ICS group, both in all-cause (403.08 vs 474.50 USD per patient per month [PPPM], cost ratio 1.18, 95% confidence interval [CI]=1.10-1.26, p<0.0001) and COPD-related (216.37 vs 267.32 USD PPPM, cost ratio 1.24, 95% CI=1.13-1.35, p<0.0001) medical costs. All-cause HCRU was not significantly different between groups, while COPD-related HRCU was higher in LAMA group (0.66 vs 0.60 medical visits PPPM, p<0.0001).

Conclusion

COPD patients initiating treatment with LAMA were associated with lower all-cause and COPD-related medical costs than those starting with LABA/ICS despite the similar all-cause HCRU and higher COPD-related HCRU. Initiation with LAMA is a cost-efficient option for the treatment of COPD.

Clinical Characteristics and Frequency of Chronic Obstructive Pulmonary Disease Exacerbations in Korean Patients: Findings From the KOCOSS Cohort 2012-2021

BACKGROUND

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) exert a substantial burden on patients and healthcare systems; however, data related to the frequency of AECOPD in the Korean population are limited. Therefore, this study aimed to describe the frequency of severe, and moderate or severe AECOPD, as well as clinical and demographic characteristics of patients with chronic obstructive pulmonary disease (COPD) in South Korea.

METHODS

Data from patients aged > 40 years with post-bronchodilator forced expiratory volume in 1 second (FEV1)/forced vital capacity ≤ 70% of the normal predicted value from the Korea COPD Subgroup Study database were analyzed (April 2012 to 2021). The protocol was based on the EXAcerbations of COPD and their OutcomeS International study. Data were collected retrospectively for year 0 (0-12 months before study enrollment) based on patient recall, and prospectively during years 1, 2, and 3 (0-12, 13-24, and 25-36 months after study enrollment, respectively). The data were summarized using descriptive statistics.

RESULTS

Data from 3,477 Korean patients (mean age, 68.5 years) with COPD were analyzed. Overall, most patients were male (92.3%), former or current smokers (90.8%), had a modified Medical Research Council dyspnea scale score ≥ 1 (83.3%), and had moderate airflow limitation (54.4%). The mean body mass index (BMI) of the study population was 23.1 kg/m², and 27.6% were obese or overweight. Hypertension was the most common comorbidity (37.6%). The mean blood eosinophil count was 226.8 cells/μL, with 21.9% of patients having ≥ 300 cells/μL. A clinically insignificant change in FEV1 (+1.4%) was observed a year after enrollment. Overall, patients experienced a mean of 0.2 severe annual AECOPD and approximately 1.1 mean moderate or severe AECOPD. Notably, the rates of severe AECOPD remained generally consistent over time. Compared with patients with no exacerbations, patients who experienced severe exacerbations had a lower mean BMI (21.7 vs. 23.1 kg/m²; P < 0.001) and lower lung function parameters (all P values < 0.001), but reported high rates of depression (25.5% vs. 15.1%; P = 0.044) and anxiety (37.3% vs. 16.7%; P < 0.001) as a comorbidity.

CONCLUSION

Findings from this Korean cohort of patients with COPD indicated a high exacerbation burden, which may be attributable to the unique characteristics of the study population and suboptimal disease management. This highlights the need to align clinical practices with the latest treatment recommendations to alleviate AECOPD burden in Korea.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05750810.

Factors affecting work productivity and activity impairment among chronic obstructive pulmonary disease patients

Chronic obstructive pulmonary disease (COPD) can negatively affect patients' employment and work-life activities with a significant indirect economic impact. The current study aimed to measure unemployment, work productivity, activity impairment, and their associated factors among COPD patients. A cross-sectional study was conducted in the Chest outpatient clinic, Mansoura University Hospital, Egypt. COPD patients completed an interviewer-administered questionnaire including sociodemographic, occupational data, clinical history, medical research council (mMRC) dyspnea scale, the COPD assessment test (CAT), and work productivity and activity impairment Questionnaire (WPAI-COPD). A total 140 patients were included in the study and 22.1% of them gave up their jobs because of their COPD. Due to COPD, the mean percentage of daily activity impairment was 39.8 among all patients. The mean percentages of absenteeism, presenteeism, and overall work impairment among the 84 working patients were 0.07, 24.4, and 24.5. The CAT score was the significant predictor of all components of WPAI. In conclusion, COPD causes early retirement, high work productivity loss, and impaired daily activities. Higher CAT scores and increased disease severity significantly increase absenteeism, presenteeism, overall work, and activity impairment. Thus, timely diagnosis of COPD with appropriate management can help improve outcomes and lower the disease burden and economic impact.

Out-of-pocket costs associated with chronic respiratory diseases in Korean adults

OBJECTIVES

Chronic respiratory diseases (CRDs) are a burden on both individuals and society. While previous literature has highlighted the clinical burden and total costs of care, it has not addressed patients' direct payments. This study aimed to estimate the incremental healthcare costs associated with patients with CRDs, specifically out-of-pocket (OOP) costs.

METHODS

We used survey data from the 2019 Korea Health Panel Survey to estimate the total OOP costs of CRDs by comparing the annual hospitalizations, outpatient visits, emergency room visits, and medications of patients with and without CRDs. Generalized linear regression models controlled for differences in other characteristics between groups.

RESULTS

We identified 222 patients with CRDs, of whom 166 were aged 65 years and older. Compared with the non-CRD group, CRD patients spent more on OOP costs (238.3 USD on average). Incremental costs were driven by outpatient visits and medications, which are subject to a coinsurance of 30% or more and may include items not covered by public insurance. Moreover, CRD patients aged 50-64 years incurred the highest incremental costs.

DISCUSSION

The financial burden associated with CRDs is significant, and outpatient visits and medications constitute the largest components of OOP spending. Policymakers should introduce appropriate strategies to reduce CRD-associated burdens.

Clinical significance of normalized airflow obstruction in patients with chronic obstructive pulmonary disease

BACKGROUND

There is ongoing debate regarding the diagnostic criteria for chronic obstructive pulmonary disease (COPD); recent studies have focused on the early COPD detection and management. Here, we compared clinical features and prognosis in patients with FEV1/FVC<0.70 at baseline, according to normalized airflow obstruction status during follow-up.

METHODS

We used the Korea COPD Subgroup Study (KOCOSS) cohort database, a prospective nationwide observational COPD study. Normalized obstruction (NO) was defined as FEV1/FVC ≥0.7 in the 2-year follow-up period, whereas fixed obstruction (FO) was defined as FEV1/FVC <0.7. Demographic and clinical data, 1-year exacerbation risk and difference in FEV1 decline over 2 years were compared between NO and FO groups.

RESULTS

Among the 670 COPD patients with post-bronchodilator FEV1/FVC <0.7 in this study, 95 (14.2%) displayed NO. Compared with the FO group, the NO group had higher FEV1, and DLCO, body mass index, as well as lower Saint George Respiratory Questionnaire, Beck Depression Index, and Beck Anxiety Index. Blood eosinophil count, IgE level, and FeNO did not significantly differ between two groups. There was no significant difference in exacerbation frequency between the two groups, but the NO group had a significant increase in FEV1 compared with the FO group during follow-up.

CONCLUSION

Transient airflow obstruction in the NO group may represent a clinical manifestation of early COPD; close monitoring is needed for such patients.

Clinical Characteristics of Non-Smoking Chronic Obstructive Pulmonary Disease Patients: Findings from the KOCOSS Cohort

Chronic obstructive pulmonary disease (COPD) has been regarded as a disease of smokers, but the prevalence of non-smoking COPD patients have been reported to be considerable. We investigated differences in clinical characteristics between smoking and non-smoking COPD patients. We used data from the Korea COPD Subgroup Study (KOCOSS) database, which is a multicenter cohort that recruits patients from 54 medical centres in Korea. Comprehensive comparisons of smoking and non-smoking COPD patients were performed based on general characteristics, exacerbations, symptom scores, radiological findings, and lung-function tests. Of the 2477 patients included in the study, 8.1% were non-smokers and 91.9% were smokers. Non-smoking COPD patients were more likely to be female and to have a higher body mass index and lower level of education. Non-smoking COPD patients had more comorbidities, including hypertension, osteoporosis, and gastroesophageal reflux disease, and experienced more respiratory and allergic diseases. No significant differences in exacerbation rates, symptom scores, or exercise capacity scores were observed between the two groups. Smoking COPD patients had more emphysematous lung according to the radiological findings, and non-smoking patients had more tuberculosis-destroyed lung and bronchiectasis. Lung-function testing revealed no significant difference in the forced expiratory capacity in 1 sec between the two groups, but smokers had more rapid lung-function decline in the 5 years of follow-up data. We found differences in general characteristics and radiological findings between smoking and non-smoking COPD patients. No significant differences in exacerbation or symptom scores were observed, but decline in lung function was less steep in non-smoking patients.Supplemental data for this article is available online at https://doi.org/10.1080/15412555.2022.2053088 .

Economic Burden of Chronic Obstructive Pulmonary Disease and Lung Cancer Between 2000 and 2015 in Saskatchewan: Study Protocol

Background

Chronic obstructive pulmonary disease (COPD) and lung cancer are both detrimental diseases that present great burdens on society. Years of life lost (YLL), premature years of life lost (PYLL), working years lost (WYL), and productivity loss are all effective measures in identifying economic burden of disease.

Objective

We propose a population-based study to analyze comprehensive provincial cohorts of Saskatchewan residents with COPD, lung cancer, and combined COPD and lung cancer in order to identify the burden these diseases present.

Methods

Saskatchewan residents over the age of 35 years who had COPD, lung cancer, or both, between January 1, 2000, and December 31, 2015, will be identified and used in this study. Data for analysis including age, gender, and date of death, alongside Statistics Canada income estimates, will be used to estimate productivity loss and WYL. Statistics Canada life tables will be used to calculate YLL and PYLL by subtracting the patients’ ages at death by their life expectancies, adjusted using sex and age at death. We will link the Saskatchewan cancer registry with Saskatchewan health administrative databases to create three cohorts: (1) COPD; (2) lung cancer; and (3) COPD and lung cancer. Individuals with lung cancer will be identified using ICDO-T (International Classification of Diseases for Oncology-Topography) codes, and those with COPD will be defined and identified as individuals who had at least 1 visit to a physician with a diagnosis of COPD or 1 hospital separation with a diagnosis of COPD. Those without a valid health care coverage for a consecutive 12 months prior to the first diagnostic code will be excluded from the study. Those with a combined diagnosis of COPD and lung cancer will be identified as individuals who were diagnosed with COPD in the 12 months following their lung cancer diagnosis or anytime preceding their lung cancer diagnosis.

Results

As of April 2021, we have had access to all relevant data for this study, have received funding (January 2020), and have begun the preliminary analysis of our data set.

Conclusions

It is well documented that COPD and lung cancer are both destructive diseases in terms of YLL, PYLL, WYL, and productivity loss; however, no studies have been conducted to analyze a cohort with combined COPD and lung cancer. Understanding the economic burden associated with each of our 3 cohorts is necessary in understanding and thus reducing the societal impact of COPD and lung cancer.

International Registered Report Identifier (IRRID)

RR1-10.2196/31350

Digital Healthcare for Airway Diseases from Personal Environmental Exposure

Digital technologies have emerged in various dimensions of human life, ranging from education to professional services to well-being. In particular, health products and services have expanded by the use and development of artificial intelligence, mobile health applications, and wearable electronic devices. Such advancements have enabled accurate and updated tracking and modeling of health conditions. For instance, digital health technologies are capable of measuring environmental pollution and predicting its adverse health effects. Several health conditions, including chronic airway diseases such as asthma and chronic obstructive pulmonary disease, can be exacerbated by pollution. These diseases impose substantial health burdens with high morbidity and mortality. Recently, efforts have been made to develop digital technologies to alleviate such conditions. Moreover, the COVID-19 pandemic has facilitated the application of telemedicine and telemonitoring for patients with chronic airway diseases. This article reviews current trends and studies in digital technology utilization for investigating and managing environmental exposure and chronic airway diseases. First, we discussed the recent progression of digital technologies in general environmental healthcare. Then, we summarized the capacity of digital technologies in predicting exacerbation and self-management of airway diseases. Concluding these reviews, we provided suggestions to improve digital health technologies' abilities to reduce the adverse effects of environmental exposure in chronic airway diseases, based on personal exposure-response modeling.

Comparison of Risk of Pneumonia Caused by Fluticasone Propionate versus Budesonide in Chronic Obstructive Pulmonary Disease: A Nationwide Retrospective Cohort Study

Introduction

Inhaled corticosteroids (ICSs) play an important role in lowering the risk of acute exacerbation of chronic obstructive pulmonary disease (COPD). However, ICSs are known to increase the risk of pneumonia. Moreover, previous studies have shown that the incidence rate of pneumonia varies depending on the type of ICS. In this study, the risk of pneumonia according to the type of ICS was investigated in a population-based cohort.

Methods

A retrospective cohort study was conducted using claims data of the entire population from the Korean National Health Insurance Service. Patients who were newly diagnosed with COPD and prescribed fluticasone propionate or budesonide were enrolled as study subjects. Cumulative doses of ICSs were classified into categorical variables to analyze the risk of pneumonia within identical ICS doses.

Results

A total of 47,473 subjects were identified and allocated as 14,518 fluticasone propionate and 14,518 budesonide users through 1:1 propensity score matching. Fluticasone propionate users were more likely to develop pneumonia than budesonide users (14.22% vs 10.66%, p<0.0001). The incidence rate per 100,000 person-years was 2,914.77 for fluticasone propionate users and 2,102.90 for budesonide users. The hazard ratio (HR) of pneumonia in fluticasone propionate compared to budesonide was 1.34 (95% CI 1.26–1.43, p<0.0001). The risk of pneumonia for fluticasone propionate compared to budesonide increased with higher ICS cumulative doses: 1.06 (0.93–1.21), 1.41 (1.19–1.66), 1.41 (1.23–1.63), and 1.49 (1.33–1.66) from the lowest to highest quartiles, respectively.

Conclusion

ICS types and doses need to be carefully considered during treatment with ICSs in patients with COPD.

Word Embedding Reveals Cyfra 21-1 as a Biomarker for Chronic Obstructive Pulmonary Disease

BACKGROUND

Although patients with chronic obstructive pulmonary disease (COPD) experience high morbidity and mortality worldwide, few biomarkers are available for COPD. Here, we analyzed potential biomarkers for the diagnosis of COPD by using word embedding.

METHODS

To determine which biomarkers are likely to be associated with COPD, we selected respiratory disease-related biomarkers. Degrees of similarity between the 26 selected biomarkers and COPD were measured by word embedding. And we infer the similarity with COPD through the word embedding model trained in the large-capacity medical corpus, and search for biomarkers with high similarity among them. We used Word2Vec, Canonical Correlation Analysis, and Global Vector for word embedding. We evaluated the associations of selected biomarkers with COPD parameters in a cohort of patients with COPD.

RESULTS

Cytokeratin 19 fragment (Cyfra 21-1) was selected because of its high similarity and its significant correlation with the COPD phenotype. Serum Cyfra 21-1 levels were determined in patients with COPD and controls (4.3 ± 5.9 vs. 3.9 ± 3.6 ng/mL, P = 0.611). The emphysema index was significantly correlated with the serum Cyfra 21-1 level (correlation coefficient = 0.219, P = 0.015).

CONCLUSION

Word embedding may be used for the discovery of biomarkers for COPD and Cyfra 21-1 may be used as a biomarker for emphysema. Additional studies are needed to validate Cyfra 21-1 as a biomarker for COPD.

Cost analysis of chronic obstructive pulmonary disease (COPD): a systematic review

BACKGROUND

Chronic Obstructive Pulmonary Disease (COPD) is a treatable disease with a high prevalence, and high morbidity associated with significant socioeconomic costs.

OBJECTIVE

To carry out a systematic review of the literature to analyze the main cost studies associated with COPD, in order to determine the main factors that influence the costs of the disease.

METHODS

Searches were conducted in PubMed, SCOPUS and Web of Science databases for cost studies on COPD published in English, between the years 2015 and 2020. The search terms were "COPD" OR "pulmonary disease, chronic obstructive", "cost*" OR "cost of illness", "economic impact" AND "burden of disease". The inclusion criteria included the identification of reported cost of the disease, economic burden, medical care expenses or use resources for COPD, the methodology used, data sources, and variables studied.

RESULTS

18 publications were analyzed: 17 included direct health costs, 6 included direct non-medical costs, 12 analyzed indirect costs and two reported intangible costs. Most of the studies reported data for developed and European countries, with direct costs being the most studied. Trends were observed in multiple studies of direct and healthcare costs for European countries measured by patient and year, where the higher costs were associated with more severe COPD and a frequent history of exacerbations. The highest costs reported corresponded to hospitalizations and the associated pharmacological treatment. The importance of the loss of productivity and premature retirement within the profile of the COPD patient was also highlighted as the main generator of indirect costs of the disease.

CONCLUSION

COPD generates substantial costs for the health system, mainly related to moderate to severe stages and the exacerbations and complications entailed. It is important to strengthen health systems with monitoring, evaluation and health education models that allow these patients to remain stable to avoid decompensation and subsequent hospitalizations.

The Association with COPD Readmission Rate and Access to Medical Institutions in Elderly Patients

Purpose

Up to 20% of patients with chronic obstructive pulmonary disease (COPD) require re-admission within 30 days of discharge after hospitalization for acute exacerbations of the disease. These re-admissions can increase morbidity and the economic burden of COPD. Reducing re-admissions has become a policy target in many developed countries. We investigated the risk factors for COPD re-admissions among older adults with COPD.

Patients and Methods

Data obtained from the National Health Insurance Service-Senior Cohort (NHIS-SC) in Korea were analyzed. The subjects included 558,147 patients aged ≥70 who had been admitted for COPD between 2013 and 2015. Re-admission was defined as being re-hospitalized within 30 days after discharge. The key variables selected from the database included income-based insurance contributions, demographical variables, information on inpatient medical services, types of healthcare facilities, and emergency time relevance index (TRI). The TRI is a regional medical-use analysis index that evaluates whether the capacity of the medical services available is appropriate for the medical needs of the target residents.

Results

In 814 COPD re-admission cases among 4867 total admissions due to COPD in elderly subjects, higher re-admission rates were associated with male sex, admission to district hospitals, medical aid recipients, and a longer hospital stay. When additionally adjusting the TRI to identify the difference in re-admission rates due to medical service accessibility, the same results were found, except for the areas of residence. The TRI was lower in re-admission cases (odds ratio 0.991 [95% CI, 0.984‒0.998], P = 0.013).

Conclusion

In this study, COPD re-admission rates among older adults were significantly associated with sex, length of hospital stay, and the type of hospital. The capacity of the medical services provided was also related to the COPD re-admission rate. Better access to appropriate emergency services is associated with reduction of COPD re-admission rates.

The current status of chronic obstructive pulmonary disease awareness, treatments, and plans for improvement in South Korea: a narrative review

The prevalence of chronic obstructive pulmonary disease (COPD) is high in South Korea which has remained virtually unchanged over the past few years. Other challenges related to COPD in South Korea include a low level of awareness of COPD, underutilization of pulmonary function tests (PFTs) and a low level of inhaler use. Continued efforts have been made to raise awareness of COPD in the general public and promote screening tests for the early detection of COPD patients for high-risk patients, which should be the primary object for better management of the disease. The Korean Academy of Tuberculosis and Respiratory Diseases (KATRD) and the Korea Disease Control and Prevention Agency (KDCA) have been working in tandem on numerous projects to resolve these issues. As the fruit of these efforts, a couple of projects are currently being carried out to add PFTs into the National Health Examination (NHE) of Korea as part of screening tests and improve the quality of COPD treatments in primary care settings. Raising public awareness of a chronic disease such as COPD requires collective efforts of academic societies and government. In addition, personalized education programs that are tailored to individual COPD patients is a necessity to raise adherence of treatment and self-management of COPD. The aim of this manuscript is to report the current status of COPD management in South Korea in hopes that it will help better treat and manage COPD in other nations coping with similar challenges.

Epidemiology, burden, and policy of chronic obstructive pulmonary disease in South Korea: a narrative review

Chronic obstructive pulmonary disease (COPD) is a global health problem and a significant cause of mortality and morbidity worldwide. COPD also occupies a significant and considerable economic burden on individuals and society in South Korea. We investigated the epidemiology and burden of COPD in South Korea and reviewed the policy regarding COPD. In South Korea, a national COPD prevalence survey has been conducted for two decades. The prevalence of COPD has increased with increasing age, particularly among males, and those also with a higher smoking history and with lower income. The total societal cost of COPD increased by 1.85 times between 2004 and 2013. As the use of inhaled medications has increased, the total medical cost per person has increased. The trends of increasing numbers of patients diagnosed with COPD and the total societal costs are expected to continue. There is one universal-health-coverage system in South Korea. The costs and reimbursement criteria of COPD drugs are established and controlled by the Health Insurance Review and Assessment Service (HIRA). The HIRA has also implemented quality assessment, including evaluating the appropriateness of a COPD diagnosis and treating all COPD patients to reduce the severity of illness and improve the adequacy of medical-care benefits.

Comorbidities and Factors Determining Medical Expenses and Length of Stay for Admitted COVID-19 Patients in Korea

Purpose

No previous investigations of coronavirus disease 2019 (COVID-19) have estimated medical expenses, length of stay, or factors influencing them using administrative datasets. This study aims to fill this research gap for the Republic of Korea, which has over 10,000 confirmed COVID-19 cases.

Patients and Methods

Using the nationwide health insurance claims data of 7590 confirmed COVID-19 patients, we estimated average medical expenses and inpatient days per patient, and performed multivariate negative binomial, and gamma regressions to determine influencing factors for higher outcomes.

Results

According to the results, COVID-19 patients with history of ICU admission, chest CT imaging, lopinavir/ritonavir and hydroxychloroquine use stayed longer in the hospital and spent more on medical expenses, and anti-hypertensive drugs were insignificantly associated with the outcomes. Female patients stayed longer in the hospital in the over 65 age group but spent less in medical expenses that the 20-39 group. In the 40-69 age group, patients with health insurance stayed longer in the hospital and spent more on medical expenses than those aged over 65 years. Comorbidities did not affect outcomes in most age groups.

Conclusion

In summary, contrary to popular beliefs, medical expenses and length of hospitalization were mostly influenced by age, and not by comorbidities, anti-viral, or anti-hypertensive drugs. Thus, responses should focus on infection prevention and control rather than clinical countermeasures.

Predicting long-term mortality with two different criteria of exercise-induced desaturation in COPD

BACKGROUND

There are few reports on exercise-induced desaturation (EID) as a predictor of mortality in chronic obstructive pulmonary disease (COPD). However, the definitions of EID vary in published reports. The main purpose was to evaluate the association between EID and long-term mortality by applying two criteria of EID.

METHODS

A total of 507 subjects were selected from the Korean Obstructive Lung Disease cohort. EID was assessed using the 6-min walk test (6MWT) and defined using two different criteria [1]: post-6MWT oxygen saturation (SpO₂) of ≤88% (criterion A) and [2] post-6MWT SpO₂ < 90% or a decrease of ≥4% compared to baseline (criterion B).

RESULTS

The prevalence of EID was 5.1% based on criterion A and 13.0% based on criterion B. Regardless of the criteria used, mortality was higher in the EID group than in the non-EID group (A: 50 vs. 11.4%, B: 33.3 vs. 10.4%) during up to 161 months of follow-up. COPD patients without EID survived significantly longer than those with EID (A: 143.5 vs. 92.9, B: 144.8 vs. 115.2 months). Multivariate Cox regression analysis revealed that COPD patients with EID had a 2.4-fold increased risk of death by criterion A (adjusted HR 2.375; 95% CI: 1.217-4.637; P = 0.011). The risk of death increased in COPD patients with EID by criterion B, but the difference was not statistically significant.

CONCLUSIONS

COPD patients with EID demonstrated significantly higher long-term mortality than those without EID. The EID criterion A has a better predictive value for mortality in COPD.

Hospitalization increases while economic status deteriorates in late stages of chronic obstructive pulmonary disease: the Korean National Health and Nutrition Examination Survey for 2007-2015

Background

Chronic obstructive pulmonary disease (COPD) is associated with frequent hospitalizations, higher mortality, and healthcare costs. Low-income COPD patients have higher rates of emergency department visits and hospitalization due to COPD exacerbation. However, other causes of admissions and their economic burden have not been well-elucidated.

Methods

We analyzed the Korean National Health and Nutrition Examination Survey (KNHANES) dataset for 2007-2015. The diagnosis and staging of COPD were based on the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines.

Results

Among the 97,622 participants in KNHANES for 2007-2015, we selected 33,963 participants (4,430 with and 29,533 without COPD) aged ≥40 years, who underwent spirometry, and provided the admission history for the previous year. Participants with COPD had a higher admission rate than those without COPD (12.8% vs. 10.4%, P<0.001). The admission rate increased as the stage of COPD advanced from GOLD 1 to GOLD 4 for total causes (11.5%, 13.6%, 15.1%, and 25.0%, respectively, P<0.001) and respiratory illnesses (0.5%, 1.3%, 4.6%, and 12.5%, respectively, P<0.001). The proportion of the lowest quartile household income increased in the late stages of COPD (GOLD 1-4; 35.2%, 32.1%, 44.9%, and 70.8%, respectively, P<0.01).

Conclusions

The hospitalization rate increased in advanced COPD, while GOLD stages 3 and 4 were associated with deterioration in economic status.

Updated view on the treatment of chronic obstructive pulmonary disease in Korea

Chronic obstructive pulmonary disease (COPD) is prevalent (13.4% in the population above the age of 40) but less recognized by patients and physicians in Korea. The definition and treatment strategies of COPD have changed with the accumulation of evidence, and the Korean COPD guidelines recommended by the Korean Academy of Tuberculosis and Respiratory Disease have also been updated. This review will cover some important points, that should be considered in the management of stable COPD in clinical practice. COPD is a treatable disease and earlier detection should be emphasized to achieve better clinical benefits in the mild stages. In addition, etiologies other than smoking are critical in the development of COPD. Medical treatment strategies have been updated focusing on the role of long-acting bronchodilators and the updated Korean COPD guidelines include specific Korean situations in the management of COPD.

Direct Switch from Tiotropium to Indacaterol/Glycopyrronium in Chronic Obstructive Pulmonary Disease Patients in Korea

Background

Many chronic obstructive pulmonary disease (COPD) patients receiving monotherapy continue to experience symptoms, exacerbations and poor quality of life. This study aimed to assess the efficacy and safety of direct switch from once-daily tiotropium (TIO) 18 μg to indacaterol/glycopyrronium (IND/GLY) 110/50 μg once daily in COPD patients in Korea.

Methods

This was a randomized, open-label, parallel group, 12-week trial in mild-to-moderate COPD patients who received TIO 18 μg once daily for ≥12 weeks prior to study initiation. Patients aged ≥40 years, with predicted post-bronchodilator forced expiratory volume in 1 second (FEV₁) ≥50%, post-bronchodilator FEV₁/forced vital capacity <0.7 and smoking history of ≥10 pack-years were included. Eligible patients were randomized in a 1:1 ratio to either IND/GLY or TIO. The primary objective was to demonstrate superiority of IND/GLY over TIO in pre-dose trough FEV₁ at week 12. Secondary endpoints included transition dyspnea index (TDI) focal score, COPD assessment test (CAT) total score, and rescue medication use following the 12-week treatment, and safety assessment.

Results

Of the 442 patients screened, 379 were randomized and 347 completed the study. IND/GLY demonstrated superiority in pre-dose trough FEV₁ versus TIO at week 12 (least squares mean treatment difference [Δ], 50 mL; p=0.013). Also, numerical improvements were observed with IND/GLY in the TDI focal score (Δ, 0.31), CAT total score (Δ, −0.81), and rescue medication use (Δ, −0.09 puffs/day). Both treatments were well tolerated by patients.

Conclusion

A direct switch from TIO to IND/GLY provided improvements in lung function and other patient-reported outcomes with an acceptable safety profile in patients with mild-to-moderate airflow limitation.

Health Effects of Ozone on Respiratory Diseases

Ozone is known to cause bronchial inflammation and airway hyper-responsiveness via oxidative injury and inflammation. While other ambient air pollutants such as particulate matter (PM) and nitrogen dioxide showed decreasing trends in mean annual concentrations, ozone concentrations have not declined recently in most countries across the world. Short-term exposure to high concentrations of ozone has been associated with increased mortality and cardiovascular and respiratory morbidity in many regions of the world. However, the long-term effects of ozone have been less investigated than the short-term exposure due to the difficulty in modeling ozone exposure and linking between individual exposures and health outcome data. A recently developed model of ozone exposure enabled the investigation of long-term ozone effects on health outcomes. Recent findings suggested that long-term exposure to ozone was associated with an increased risk of cardiovascular and respiratory mortality. Longitudinal studies using large cohorts also revealed that long-term exposure to ozone was associated with a greater decline in lung function and the progression of emphysema. The development of long-term standards for ozone as well as PM should be considered to protect the respiratory health of the general population and people with chronic respiratory diseases.

Nationwide quality assessment of treatment for chronic obstructive pulmonary disease

Background

Chronic obstructive pulmonary disease (COPD) requires careful ambulatory care. If treatment is effective, exacerbation and hospitalization can be preventable. Appropriate management is important; the disease prevalence is high, as is the demand on healthcare resources. Here, we have reported the results of nationwide quality assessment performed with the aims of improving patient management, reducing progression to severe status, and minimizing medical care expenses.

Methods

The Health Insurance Review and Assessment Service (HIRA) engaged in quality assessment three times from May 2014 to April 2017. Medical care institutions were evaluated in terms of the pulmonary function test (PFT), patient revisit, and inhaled bronchodilator prescription rates.

Results

The numbers of patients assessed were 141,782, 142,790, and 143,339 in years 1, 2, and 3, respectively; the numbers of medical care institutions assessed were 6,691, 6,722, and 6,470, respectively. The PFT implementation rates were 58.7%, 62.5%, and 67.9% for years 1, 2, and 3, respectively; these rates were highest for tertiary hospitals, followed by general and local hospitals, as well as primary healthcare clinics. The repeat visit rates were 85.5%, 92.1%, and 85.0% for years 1, 2, and 3, respectively; these rates were highest for general hospitals, followed by local and tertiary hospitals, and primary healthcare clinics. The inhaled bronchodilator prescription rates were 67.9%, 71.2%, and 76.9% for years 1, 2, and 3, respectively; these rates increased with increasing hospital grade.

Conclusions

The PFT and inhaled bronchodilator prescription rates improved over the 3-year nationwide quality assessment period.

Impact of a Clinical Pharmacist Intervention on Medicine Costs in Patients with Chronic Obstructive Pulmonary Disease in India

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality, especially in low- and middle-income countries (LMICs) such as India. Medicine costs are a key issue in LMICs, with typically high patient co-payments. In addition, pharmacists are underutilised in LMICs, including India. However, pharmacist-led educational interventions may improve the care of patients with COPD, as well as reduce medicine costs. Consequently, the objective of this study was to assess the effectiveness of a pharmacist-led intervention in reducing medicine costs.

METHODOLOGY

We assessed the impact of a pharmacist intervention on direct medicine costs in COPD patients (medicine costs and pharmacist time) in a randomised controlled study involving an intervention and control group, conducted at a tertiary care teaching hospital in India.

RESULTS

The 6-monthly cost of medicines at baseline increased with disease severity, from a maximum of US$29.46 for those with mild COPD to US$63.28 for those with very severe COPD. Substantial savings in medical costs were achieved with the pharmacist-led programme, to a maximum of US$20.49 over 6 months for very severe patients. This equates to a reduction of 30.6% in medicine costs (p < 0.001), reduced to 26.1% when pharmacists' time (US$3.00/patient) was included.

CONCLUSION

There could be a key role for pharmacists as educators for COPD patients in LMICs, to improve care and reduce costs, including patient co-payments.

Does benralizumab effectively treat chronic obstructive pulmonary disease? A protocol of systematic review and meta-analysis

BACKGROUND

This study aims to investigate the efficacy and safety of benralizumab for the treatment of patients with chronic obstructive pulmonary disease (COPD).

METHODS

This study will systematically and comprehensively search relevant literatures in electronic databases (MEDLINE, EMBASE, Cochrane Library, Global health, PsycINFO, Scopus, WANGFANG, and CNKI) from inception to the present without language and publication time restrictions. Two reviewers will independently carry out literature identification, data collection, and study quality assessment. Any disagreement will be settled down by a third reviewer through discussion and a consensus will be reached. RevMan 5.3 software will be used for statistical analysis performance.

RESULTS

This study will summarize up-to-date evidence to assess the efficacy and safety of benralizumab for the treatment of COPD.

CONCLUSION

The findings of this study will provide helpful evidence to determine whether benralizumab is effective or not for the treatment of COPD.

SYSTEMATIC REVIEW REGISTRATION

INPLASY202040039.

Polyunsaturated fatty acids, lung function, and health-related quality of life in patients with chronic obstructive pulmonary disease

Background

Dietary polyunsaturated fatty acids (PUFA) are thought to modify systemic inflammation. The present study aimed to evaluate the relationship between PUFA intake, lung function, and health-related quality of life (HRQoL) in patients with chronic obstructive pulmonary disease (COPD).

Methods

In this study, we used the dataset of 6th Korea National Health and Nutrition Examination Survey, in which, a total of 22,948 individuals including 573 participants with a high probability of developing COPD were enrolled. Participants with missing data for the investigated variables were excluded. Linear regression analyses were used to evaluate the association between PUFA intake (omega-3 [N3], omega-6 [N6], and total) with lung function, and HRQoL. HRQoL was determined according to the European Quality of Life-5 Dimensions (EQ-5D). Subgroup analysis of older patients was performed. Age, sex, body mass index, smoking, alcohol, education, residence, total calorie intake, and predicted FEV₁% were adjusted in all analyses.

Results

Although lung function was not associated with PUFA intake, EQ-5D index was remarkably associated with N3, N6, and total PUFA intake in a dose-dependent manner. This association was more pronounced in elderly COPD patients. Mean levels of N3, N6, and total PUFA intake were significantly higher in patients having better HRQoL with respect to mobility, self-care, and usual activities.

Conclusion

Our results suggest that N3, N6, and total PUFA intake are associated with HRQoL in COPD patients. This association may be attributed to mobility, self-care, and usual activities. Further longitudinal study is required to clarify this relationship.

Role of phosphodiesterase-4 inhibitors in chronic obstructive pulmonary disease

Phosphodiesterase-4 inhibitors (PDE4Is) are potent anti-inf lammatory agents and roflumilast has been used to prevent acute exacerbation of chronic obstructive pulmonary disease (COPD). Roflumilast decreases neutrophil migration, restores cystic fibrosis transmembrane conductance regulator activity, and recovers glucocorticoid effects. A forced expiratory volume in 1 second of < 50%, a chronic bronchitis phenotype, high blood eosinophil levels, and a history of hospitalization are biomarkers for predicting responses to roflumilast. Adverse effects are common in clinical practice. An inhaled PDE4I has recently been developed and is under clinical trial. CHF6001 and RPL554 exhibit promise and may be future treatment options for COPD.

Severe vitamin D deficiency is associated with emphysema progression in male patients with COPD

BACKGROUND

Patients with chronic obstructive pulmonary disease (COPD) have an increased risk of vitamin D deficiency. Vitamin D levels also correlate with lung function in patients with COPD. However, there are few reports on vitamin D deficiency and emphysema severity in COPD. This study aimed to investigate the effects of plasma 25-hydroxyvitamin D (25-OHD) level on emphysema severity in male COPD patients.

METHODS

A total of 151 male subjects were selected from the Korean Obstructive Lung Disease (KOLD) cohort. Subjects were subdivided into four subgroups according to their baseline plasma 25-OHD level: sufficiency (≥20 ng/ml), mild deficiency (15-20 ng/ml), moderate deficiency (10-15 ng/ml), and severe deficiency (<10 ng/ml).

RESULTS

Baseline computed tomography (CT) emphysema indices revealed significant differences among the subgroups (p = 0.034). A statistically significant difference was also observed among the subgroups regarding change in the CT emphysema index over 3 years (p = 0.047). The annual increase in emphysema index was more prominent in the severe deficiency group (1.34% per year) than in the other groups (0.41% per year) (p = 0.003).

CONCLUSIONS

This study demonstrates that CT emphysema indices were different among the four subgroups and supports that severe vitamin D deficiency is associated with rapid progression of emphysema in male patients with COPD.

CAT Score and SGRQ Definitions of Chronic Bronchitis as an Alternative to the Classical Definition

Purpose

Previous studies have used various definitions to classify chronic obstructive pulmonary disease (COPD) patients into chronic bronchitis (CB) and non-CB patients. This study was performed to identify differences among three definitions of CB based on the classical method, St. George's Respiratory Questionnaire (SGRQ), and the CAT (COPD Assessment Test) score.

Patients and methods

We extracted data from the multicenter Korea COPD Subgroup Study (KOCOSS) cohort, for which patients recruited from among 47 medical centers in South Korea beginning in April 2012. Patients were classified according to three different definitions of CB: 1) classical definition; 2) SGRQ (using questions regarding cough and sputum); and 3) CAT score (comprising cough [CAT1] and sputum [CAT2] subscale scores).

Results

A total of 2694 patients were enrolled in this study. The proportions of CB were 10.8%, 35.8%, and 24.0% according to the classical, SGRQ, and CAT definitions, respectively. The three definitions yielded consistently significant differences between CB and non-CB patients in modified Medical Research Council dyspnea scale CAT score, SGRQ score, number of moderate-to-severe exacerbations per year and forced expiratory volume in 1 second. By three definitions, CB consistently predicted future risk of exacerbation. The kappa coefficient of agreement between the classical definition and SGRQ definition was 0.29, that of the classical definition and CAT definition was 0.32, and that of the SGRQ definition and CAT definition was 0.44.

Conclusion

Patients with CB according to the new definitions based on SGRQ or CAT score showed similar clinical characteristics to those defined according to the classical definition. The new CB definitions may be used as alternatives to the classical definition.