Comorbidities and Short-term Prognosis in Patients Hospitalized for Acute Exacerbation of COPD

Almagro, Pedro; Cabrera, Francisco; Díez, Jesús; Boixeda, Ramón; Ortiz, María Belén Alonso; Murio, Cristina; Soriano, Joan B.

doi:10.1378/chest.11-2413

Cited by 212 publications

(176 citation statements)

References 35 publications

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“…This is probably explained by the high co-variation effect between these factors (Pearson r ϭ 0.31, P Ͻ .001). Our predictive analysis confirms prior results showing that COPD severity (measured by FEV 1 ) [30][31][32] and the Charlson comorbidity index 32 are variables in exacerbated patients that correlate with detrimental effects on return to preexacerbation health status, 30 that are independently associated with antibiotic failure, 31 and that are related to stay and other short-term prognosis factors. 32 Although significant statistical evidence was not found, a negative trend for the use of steroids (inhaled and systemic) as concomitant medications in hospitalized patients with COPD exacerbation was shown to influence clinical cure 31 and treatment failure 32 ; however, in both studies, this observation was not the primary aim but was associated with determination of antibiotic effectiveness evaluated during the clinical course and after a COPD exacerbation event, but not at onset of COPD exacerbation.…”

Section: Discussionsupporting

confidence: 88%

Inhaled Corticosteroids Do Not Influence the Early Inflammatory Response and Clinical Presentation of Hospitalized Subjects With COPD Exacerbation

et al. 2014

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BACKGROUND: Inhaled corticosteroids are anti-inflammatory medications that can down-regulate the immunologic response in patients with COPD; however, their role at onset of COPD exacerbation is still not understood. The aim of this study was to assess the early inflammatory response and clinical presentation of patients with COPD exacerbation mediated by inhaled corticosteroids. METHODS: Prospective data were collected on 123 hospitalized subjects with COPD exacerbation over a 30-month period at 2 Spanish university hospitals. Based on domiciliary use, comparative analyses were performed between subjects who did not use inhaled corticosteroids (n ‫؍‬ 58) and subjects who did (n ‫؍‬ 65). Measurements of serum biomarkers were recorded on admission to the hospital (day 1) and on day 3; clinical, physiological, microbiological, and severity data and mortality/readmission rates were also recorded. RESULTS: At days 1 and 3, both groups showed a similar inflammatory response; fluticasone produced lower levels of interleukin-8 compared with budesonide (P < .01). All clinical features considered were similar in the 2 groups; multivariate analysis predicting clinical complications on hospitalization showed air-flow obstruction severity as the only predictive factor (odds ratio 3.13, 95% CI 1.13-8.63, P ‫؍‬ .02). CONCLUSIONS: Our study demonstrates a lack of inhaled corticosteroid influence in the early systemic inflammatory response to and clinical presentation of COPD exacerbation.

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Section: Discussionsupporting

confidence: 88%

Inhaled Corticosteroids Do Not Influence the Early Inflammatory Response and Clinical Presentation of Hospitalized Subjects With COPD Exacerbation

et al. 2014

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“…[7][8][9][10][11] Factors associated with longer stay include increased dyspnea, 7 high breathing frequency, high P aCO 2 , 19,20 comorbidities, advanced age, poor performance status, low FEV 1 , 21 and cause of exacerbations (exacerbations due to infective causes were associated with longer stay). 8 Furthermore, socioeconomic deprivation 22 and comorbid depressive symptoms 23,24 in subjects with COPD have been also related to longer hospital stay.…”

Section: Discussionmentioning

confidence: 99%

“…6,7 Despite the tremendous burden of hospital admissions, few studies have the duration of hospital stay and its association with subjects' characteristics as primary shortterm outcome parameters. 3,[7][8][9][10][11][12] Such knowledge could help clinicians to identify subjects who require intensive treatment, targeting therapeutic goals to encounter all the parameters that are relevant to increased stay to allow for better utilization of medical resources.…”

Section: Introductionmentioning

confidence: 99%

Prediction of Hospitalization Stay in COPD Exacerbations: The AECOPD-F Score

et al. 2014

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BACKGROUND: Hospital admissions for COPD exacerbations account for 70% of total costs of COPD treatment, and the duration of hospital stay is directly related to this cost. The aim of this study was to investigate possible associations of demographic, clinical, laboratory, and functional parameters with stay of subjects admitted for COPD exacerbations and to provide a score for the prediction of the need for prolonged hospitalization. METHODS: We included 164 consecutive subjects admitted to 2 respiratory medicine departments of 2 tertiary hospitals for a COPD exacerbation, and we evaluated laboratory, clinical, and functional parameters possibly related to the duration of hospital stay. RESULTS: Seven parameters evaluated on subject admission (Antonisen type of exacerbation, number of Exacerbations in the previous year, Charlson index of comorbidities, Oxygenation, Partial pressure of P aCO 2 in arterial blood gases, Dyspnea according to the Borg dyspnea scale, and history of chronic respiratory Failure) were able to predict stay and were included in a simple score named AECOPD-F. The area under the curve of the score for the prediction of prolonged hospital stay is 0.960, and a cutoff point > 3 predicts prolonged stay with a sensitivity of 84.5% and a specificity of 92.5% (95% CI 0.917-0.984). The AECOPD-F score was validated in a second group of 88 subjects admitted to the hospital for a COPD exacerbation. In the validation group, subjects with a score > 3 required prolonged stay compared with those with a score < 3 (8.0 [6.0 -10.0] vs 6.5 [4.0 -9.0] d, respectively, P ‫؍‬ .007). CONCLUSION: The AECOPD-F score could accurately predict stay in hospitalized COPD subjects. The implementation of this score in clinical practice could be useful in the discharge planning of such subjects.

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“…These risks were applied to the post-discharge health states for both the stable and post-hospital populations. While it may be the case that GOLD stage 4 patients are at high risk of readmission compared with less severe patients, 150 no prior publications have been able to differentiate GOLD stage 3 and GOLD stage 4, hence the assumption employed in the model. 151 …”

Section: Estimation Of Model Parametersmentioning

confidence: 99%

The cost-effectiveness of domiciliary non-invasive ventilation in patients with end-stage chronic obstructive pulmonary disease: a systematic review and economic evaluation

Dretzke

Blissett

Dave

et al. 2015

Health Technol Assess

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BackgroundChronic obstructive pulmonary disease (COPD) is a chronic progressive lung disease characterised by non-reversible airflow obstruction. Exacerbations are a key cause of morbidity and mortality and place a considerable burden on health-care systems. While there is evidence that patients benefit from non-invasive ventilation (NIV) in hospital during an acute exacerbation, evidence supporting home use for more stable COPD patients is limited. In the UK, domiciliary NIV is considered on health economic grounds in patients after three hospital admissions for acute hypercapnic respiratory failure.ObjectiveTo assess the clinical effectiveness and cost-effectiveness of domiciliary NIV by systematic review and economic evaluation.Data sourcesBibliographic databases, conference proceedings and ongoing trial registries up to September 2014.MethodsStandard systematic review methods were used for identifying relevant clinical effectiveness and cost-effectiveness studies assessing NIV compared with usual care or comparing different types of NIV. Risk of bias was assessed using Cochrane guidelines and relevant economic checklists. Results for primary effectiveness outcomes (mortality, hospitalisations, exacerbations and quality of life) were presented, where possible, in forest plots. A speculative Markov decision model was developed to compare the cost-effectiveness of domiciliary NIV with usual care from a UK perspective for post-hospital and more stable populations separately.ResultsThirty-one controlled effectiveness studies were identified, which report a variety of outcomes. For stable patients, a modest volume of evidence found no benefit from domiciliary NIV for survival and some non-significant beneficial trends for hospitalisations and quality of life. For post-hospital patients, no benefit from NIV could be shown in terms of survival (from randomised controlled trials) and findings for hospital admissions were inconsistent and based on limited evidence. No conclusions could be drawn regarding potential benefit from different types of NIV. No cost-effectiveness studies of domiciliary NIV were identified. Economic modelling suggested that NIV may be cost-effective in a stable population at a threshold of £30,000 per quality-adjusted life-year (QALY) gained (incremental cost-effectiveness ratio £28,162), but this is associated with uncertainty. In the case of the post-hospital population, results for three separate base cases ranged from usual care dominating to NIV being cost-effective, with an incremental cost-effectiveness ratio of less than £10,000 per QALY gained. All estimates were sensitive to effectiveness estimates, length of benefit from NIV (currently unknown) and some costs. Modelling suggested that reductions in the rate of hospital admissions per patient per year of 24% and 15% in the stable and post-hospital populations, respectively, are required for NIV to be cost-effective.LimitationsEvidence on key clinical outcomes remains limited, particularly quality-of-life and long-term (> 2 years) effects. Economic modelling should be viewed as speculative because of uncertainty around effect estimates, baseline risks, length of benefit of NIV and limited quality-of-life/utility data.ConclusionsThe cost-effectiveness of domiciliary NIV remains uncertain and the findings in this report are sensitive to emergent data. Further evidence is required to identify patients most likely to benefit from domiciliary NIV and to establish optimum time points for starting NIV and equipment settings.Future work recommendationsThe results from this report will need to be re-examined in the light of any new trial results, particularly in terms of reducing the uncertainty in the economic model. Any new randomised controlled trials should consider including a sham non-invasive ventilation arm and/or a higher- and lower-pressure arm. Individual participant data analyses may help to determine whether or not there are any patient characteristics or equipment settings that are predictive of a benefit of NIV and to establish optimum time points for starting (and potentially discounting) NIV.Study registrationThis study is registered as PROSPERO CRD42012003286.FundingThe National Institute for Health Research Health Technology Assessment programme.

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Comorbidities and Short-term Prognosis in Patients Hospitalized for Acute Exacerbation of COPD

Cited by 212 publications

References 35 publications

Inhaled Corticosteroids Do Not Influence the Early Inflammatory Response and Clinical Presentation of Hospitalized Subjects With COPD Exacerbation

Inhaled Corticosteroids Do Not Influence the Early Inflammatory Response and Clinical Presentation of Hospitalized Subjects With COPD Exacerbation

Prediction of Hospitalization Stay in COPD Exacerbations: The AECOPD-F Score

The cost-effectiveness of domiciliary non-invasive ventilation in patients with end-stage chronic obstructive pulmonary disease: a systematic review and economic evaluation

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