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Estimating mortality among inpatients with acute exacerbation of chronic obstructive pulmonary disease using registry data

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Zhengcun Pei at Tianjin University
Zhengcun Pei
Yixin Sun
Yixin Sun
Yixin Sun
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Shengfeng Wang at University of Chicago
Shengfeng Wang
Yahong Chen
Yahong Chen
Yahong Chen
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Abstract and Figures

The study aimed to investigate the demographic characteristics, clinical features, diagnoses, and treatments of hospitalized exacerbation COPD patients, as well as their disease prognoses and economic costs. The study planned to enroll 7600 hospitalized patients (aged ≥18 years with main diagnosis as AECOPD). Study patients were recruited since September 2017, followed up with a 3-year observing period. In the baseline visit, information on demographic characteristics, clinical features, diagnoses, and treatments were collected. In the following visits, treatments and examinations, recurrence of AECOPD, re-admission to hospital, complications, and mortality were recorded. Several validated questionnaires were applied at specific visits. This study included data from 1 September 2017 until 31 December 2022. The data would be used to estimate all-cause mortality during hospital stay, AECOPD recurrence within 1 month after discharge, all-cause and cause-specific mortality, frequency of AECOPD recurrence, lung function, life quality, healthcare costs in the study period, etc.
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PROTOCOL OPEN
Estimating mortality among inpatients with acute exacerbation
of chronic obstructive pulmonary disease using registry data
Zhengcun Pei
1
, Yixin Sun
1
, Shengfeng Wang
1
, Yahong Chen
2
, Ting Yang
3,4
, Kewu Huang
5,6
, Yan Zhang
7
, Yin Huang
8
,
Chen Wang
4,9
and Siyan Zhan
1
✉
The study aimed to investigate the demographic characteristics, clinical features, diagnoses, and treatments of hospitalized
exacerbation COPD patients, as well as their disease prognoses and economic costs. The study planned to enroll 7600 hospitalized
patients (aged ≥18 years with main diagnosis as AECOPD). Study patients were recruited since September 2017, followed up with a
3-year observing period. In the baseline visit, information on demographic characteristics, clinical features, diagnoses, and
treatments were collected. In the following visits, treatments and examinations, recurrence of AECOPD, re-admission to hospital,
complications, and mortality were recorded. Several validated questionnaires were applied at specific visits. This study included
data from 1 September 2017 until 31 December 2022. The data would be used to estimate all-cause mortality during hospital stay,
AECOPD recurrence within 1 month after discharge, all-cause and cause-specific mortality, frequency of AECOPD recurrence, lung
function, life quality, healthcare costs in the study period, etc.
npj Primary Care Respiratory Medicine (2020) 30:28 ; https://doi.org/10.1038/s41533-020-0186-y
INTRODUCTION
Chronic obstructive pulmonary disease (COPD), characterized by
persistent airflow limitation, is a common preventable and
treatable disease and is the leading cause of mortality and
morbidity worldwide
1
. More than three million deaths were
caused by COPD each year
2,3
. The prevalence of COPD in adults
was estimated to be 4–10% worldwide
4,5
, and 8.6% in China
6
,
accounting for approximately 100 million COPD patients.
Acute exacerbation of COPD (AECOPD), defined by the Global
Initiative for Chronic Obstructive Lung Disease, is an acute event
characterized by a worsening of the patient’s respiratory
symptoms that is beyond normal day-to-day variations and leads
to a change in medication
7–9
; the disease burden and its
exacerbations have been studied globally
3,10,11
; exacerbation is a
signal of disease progression and a major cause of patient
hospitalization.
The severity and frequency of exacerbations strongly correlated
with patient prognosis, especially mortality, whereas prevention,
early detection, and prompt treatment would predict a better
prognosis
2
. However, as the mortality data with regard to AECOPD
are limited for China, we speculated that there remains a gap
between guidelines and clinical practices in China. This multi-
center prospective patient registry study is launched to investigate
the clinical features, treatments, and prognoses of AECOPD and
meanwhile to build up a COPD management network.
The primary aim of this study was to assess the all-cause and
cause-specific mortality among patients admitted to hospital for
AECOPD and further to calculate re-admission rate caused again
by AECOPD within 1 month after discharge. The secondary aims
included analyses with regard to the 3-year follow-up after
discharge, specifically all-cause and cause-specific mortality (at 1,
2, 3 years), recurrence of AECOPD (frequency of AECOPD
recurrence, the date of first recurrence after discharge), lung
function, and quality of life assessment, as well as healthcare costs.
RESULTS
The primary aim of this study was to assess the in-hospital
mortality of AECOPD patients, to describe all-cause and cause-
specific mortality, and further to calculate re-admission rate
caused again by AECOPD within 1 month after discharge from
hospital. The secondary aims included analyses with regard to the
3-year follow-up after discharge from hospital, specifically all-
cause and cause-specific mortality (at 1, 2, 3 years), recurrence of
AECOPD (frequency of AECOPD recurrence, the date of first
recurrence after discharge), lung function, and quality of life
assessment, as well as healthcare costs.
The data obtained were planned to be used to describe the all-
cause and cause-specific mortality of AECOPD patients, re-
admission rates at the time points of 1 month to 3 years after
discharge from hospital, as well as the recurrence of AECOPD, lung
function decline, and quality of life.
Mortality rate, recurrence rate, and re-admission rate were
planned to be reported pooled and stratified by sex, age, area,
disease severity, etc. Their potential risk factors and confounders
in consideration included COPD severity (lung function, AECOPD
symptoms), medical history (COPD history, frequency of hospita-
lization, tobacco exposure, etc.), comorbidities (respiratory dis-
eases, cardiovascular diseases, metabolic diseases, digestive
diseases, etc.), treatment (bronchodilators, glucocorticoids, anti-
biotics, oxygen therapy, ventilatory support, etc.), questionnaire,
and scales (COPD assessment test (CAT), modified British Medical
Research Council (mMRC), St. George’s respiratory questionnaire
(SGRQ), hospital anxiety and depression scale (HADS)). The
1
Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China.
2
Department of Pulmonary and Critical Care Medicine, Peking University
Third Hospital, Beijing, China.
3
Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.
4
National
Clinical Research Center for Respiratory Diseases, Beijing, China.
5
Department of Pulmonary and Critical Care Medicine, Beijing ChaoYang Hospital, Beijing, China.
6
Department of
Respiratory Medicine, Capital Medical University, Beijing, China.
7
Best-Road Medi-Tech (Beijing) Ltd, Beijing, China.
8
Beijing Natureself Technology Co. Ltd, Beijing, China.
9
Chinese
Academy of Medical Sciences and Peking Union Medical College, Beijing, China. ✉email: siyan- zhan@bjmu.edu.cn
www.nature.com/npjpcrm
Published in partnership with Primary Care Respiratory Society UK
1234567890():,;
association between death event and its potential influential
factors, the association between recurrence and readmission with
their risk factors, the association between treatment and future
outcomes, and similar associations of interest were planned to be
assessed using multivariate linear/logistic regressions and Cox
regression to assess time to death and its relevant factors. A
mixed-effects model for longitudinal data analysis would be an
optional choice to validate long-term effect of potential risk
factors. In addition, comparative effectiveness research on
different inpatient therapies (bronchodilators, glucocorticoids,
antibiotics, oxygen therapy, ventilatory support) and prognoses
(recovery, death, length of hospitalization), stable COPD manage-
ment (pharmacological treatment, tobacco cessation, pulmonary
rehabilitation, oxygen therapy), and disease progression (death,
readmission, new comorbidities, lung function decline), as well as the
impact of medication adherence on disease progression were
plannedtobecomparedafterpropensity score matching. Statistical
significanceweredefined as the two-sided pvalue < 0.05. All the
data were planned to be analyzed using the R software version 3.6,
SAS V9.4 statistical package or STATA V15.0.
DISCUSSION
The ACURE (estimating mortality among inpatients with Acute
exacerbation of Chronic obstrUctive pulmonary disease using
REgistry data) study aimed to describe the overall clinical features
and treatment procedures of AECOPD patients. The data obtained
could be used to better understand the long-term outcome and
risk factors of AECOPD and lung function declines.
As a pioneering study for proper measuring mortality of
AECOPD patients all over the country, this study enabled our
clinicians and researchers to address fundamental issues regard-
ing the “real world”situation of AECOPD in China. It will also serve
as a harmonized, evidence-based registry and platform for
conducting future research, which will ultimately improve the
management care provided to AECOPD patients.
Table 1. Schematic diagram of the ACURE study.
Visit Study period
Baseline survey Follow-up survey
V0 V1 V2 V3 V4 V5 V6 V7
Time point Admission–discharge D30 M3 M6 M9 M12 M24 M36
Contact type V V P V P V V V
Eligibility screen X
Informed consent X
Demographics X
Medical history X
Personal history X
Treatment X X X X X X X X
Change of treatment for respiratory system X X X X X X X
Physical examination X
Lung function test X X X X X X
Laboratory test X X X X X X
ECG X
Lung CT X X X X
UCG X
Pulmonary perfusion imaging X
Venous ultrasound of lower extremity X
PEACE questionnaire X
a
X XXXX X X
CAT questionnaire X X X X X X X X
mMRC questionnaire X X X X X X X
SGRQ X X X X
HADS X
Prognosis (including death) X X X X X X
RICU/ICU admission X
Re-admission X X X X X X X
AECOPD assessment X X X X X X X
Lost to follow-up X X X X X
Direct cost X X X X X X X X
Inhalation equipment X
ACURE estimating mortality among inpatients with Acute exacerbation of Chronic obstrUctive pulmonary disease using REgistry data, AECOPD acute
exacerbation of chronic obstructive pulmonary disease, CAT COPD assessment test, CT computed tomography, D30 30 days after discharge, ECG
electrocardiogram, HADS hospital anxiety and depression scale, M3,M6,M9,M12 3/6/9/12 months after discharge, mMRC modified British Medical Research
Council, Pphone call, PEACE questionnaire from the study by Zheng et al.
13
,RICU respiratory intensive care unit, SGRQ St. George’s respiratory questionnaire,
UCG ultrasound cardiogram, Vvisit, Xinformation collected.
a
Everyday during hospitalization.
Z. Pei et al.
2
npj Primary Care Respiratory Medicine (2020) 28 Published in partnership with Primary Care Respiratory Society UK
1234567890():,;
The main limitations may be related to incompleteness of lung
function data, as most exacerbation patients were not able to
conduct a lung function test during hospital stay. We were aware
of this limitation and asked the patient to provide lung function
information before exacerbation or to measure lung function
during stable phase of COPD as a substitution. Additional
limitation is that selection bias may exist, as participating research
centers are leading hospitals where proportions of severe patients
are usually higher than normal population. Nevertheless, partici-
pant from diverse areas of China would represent a real nature of
COPD progression in Chinese patients. Disease progression of
mild, moderate, and severe COPD were all investigated and
discussed, regardless of their actual proportion.
METHODS
The ACURE study is an ongoing nationwide multicenter, observational
patient registry in patients admitted to hospital for AECOPD, followed up
with a 3-year observing period in a real-world setting. The first patient
recruited in the database was recorded on 1 September 2017, the
expected end of patient enrollment in all centers was December 2019, and
the expected end of patient follow-up in all centers is December 2022. The
study design schematic is shown in Table 1. Currently, 158 centers
(hospitals) dispersing over 29 provinces of China participated in this study.
The distribution of participating centers is shown in Fig. 1; each research
center was coordinated by one national expert, who was responsible for
local data collection and organization affairs that were related with this
work. In addition, a steering committee was employed for the design and
scientific integrity of the study. Table 2shows the composition of our
steering committee.
All patients with AECOPD examined by a clinical physician were eligible to
be enrolled in this study if they fulfill the following inclusion criteria: age ≥18
years and hospitalized patients with confirmed diagnosis of AECOPD. During
recruitment, we confirmed AECOPD diagnosis based on personal history and
clinical symptoms, as well as lung function level in recent 6 months, which
was recorded in hospital information system or self-reported. For patients
who had AECOPD for the firsttimeorwhohadnolungfunctiondata,we
confirmed their AECOPD diagnoses at follow-up lung function examinations,
as it is not recommended to test lung function during acute exacerbations.
Meanwhile, patients who were diagnosed as having active pulmonary
tuberculosis or acute left heart failure and patients who were participating in
clinical trials or intervention studies of drugs were excluded.
Patients were not directly involved in the design, development of
research questions or outcomes of this study. Researchers or research
assistants interpreted the questions to the participants and recorded the
answers. The results of the ACURE study will be available for the public. All
participating patients were requested to provide written informed consent.
The study had complied with all relevant ethical regulations. The study
protocol had been approved by the ethics committee of China-Japan
Friendship Hospital (approval number: 2015-88). Informed consent was
obtained from all patients of the study. The rights, safety, and well-being of
clinical investigation subjects were protected according to the ethical
principles of the Declaration of Helsinki. This study was registered in
Clinicaltrials.gov with the identifier NCT02657525.
The study protocol was designed to collect all clinical data during one
hospital stay and stable COPD management data through regular clinical
follow-ups; the observing parameters were identified and selected by all
the principle investigators from the collaborating centers together with a
panel of national experts. A paper case report form was designed to collect
research information bedside, and an electronic case report form was
designed to upload the research information to the study Electronic Data
Capture (EDC) system.
For each patient, a baseline survey was conducted within 1–3daysafter
hospitalization to collect information on medical history, physical examina-
tion, and inpatient diagnosis. During the hospital stay, information on
Fig. 1 Distribution of participating centers of the ACURE study. White and blue colors denote different center numbers across provinces.
Z. Pei et al.
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Published in partnership with Primary Care Respiratory Society UK npj Primary Care Respiratory Medicine (2020) 28
questionnaires [CAT questionnaire, PEACE questionnaire (consisting of eight
questions assessing daily variance of COPD symptoms, i.e., dyspnea,
purulent sputum, sputum volume, upper respiratory tract infection, fever,
wheeze, cough, breath rate), mMRC questionnaire], medical examinations,
laboratory tests, and treatments was recorded. Comorbidities including
respiratory diseases (pneumonia, pulmonary embolism, interstitial lung
disease, pulmonary arterial hypertension, lung cancer, asthma, respiratory
failure), cardiovascular diseases (myocardial infarction, angina pectoris,
hypertension, chronic heart failure, ventricular premature beat, right bundle
branch block, atrial fibrillation), metabolic diseases (diabetes, osteoporosis),
and digestive diseases (gastroesophageal reflux disease, peptic ulcer,
cirrhosis), as well as malignancies other than lung cancer, peripheral arterial
disease, venous thromboembolism, cerebrovascular disease, anxiety/depres-
sion, musculoskeletal dysfunction, chronic kidney disease, etc. were
recorded. When a patient was discharged from hospital, information on
diagnosis, CAT questionnaire, disease prognosis, intensive care unit stay (if
any), and costs was collected. During each follow-up visit, information on the
management; progress; recurrence; and prognosis of COPD, pharmacologi-
cal, and non-pharmacological treatment was collected; meanwhile, scale
and questionnaire surveys [CAT, mMRC, SGRQ, HADS] were conducted. An
overview of the collected data is listed in Supplementary Table 1.
The primary aim of the study was to estimate the mortality rate during
hospital stay; the sample size required is 6080 individuals, which was
calculated based on an estimated mortality rate of 5% with an absolute
precision of 2%, 95% confidence interval, and high design effect when
recruiting patients from 40 hospitals, using the software CSurvey 2.0
12
; and
finally 7600 individuals are required with an assumption of 20% drop-outs,
as loss to follow-up is inevitable in such longitudinal design.
DATA AVAILABILITY
No datasets were generated or analyzed during the current study.
CODE AVAILABILITY
No codes were generated during the current study.
Received: 3 February 2020; Accepted: 7 May 2020;
REFERENCES
1. GBD 2015 Chronic Respiratory Disease Collaborators. Global, regional, and
national deaths, prevalence, disability-adjusted life years, and years lived with
disability for chronic obstructive pulmonary disease and asthma, 1990-2015: a
systematic analysis for the Global Burden of Disease Study 2015. Lancet Respir.
Med. 5, 691–706 (2017).
2. Fang, X., Wang, X. & Bai, C. COPD in China: the burden and importance of proper
management. Chest 139, 920–929 (2011).
3. Lozano, R. et al. Global and regional mortality from 235 causes of death for 20
age groups in 1990 and 2010: a systematic analysis for the Global Burden of
Disease Study 2010. Lancet 380, 2095–2128 (2012).
4. Halbert, R. J., Isonaka, S., George, D. & Iqbal, A. Interpreting COPD prevalence
estimates: what is the true burden of disease? Chest 123, 1684–1692 (2003).
5. Buist, A. S. et al. International variation in the prevalence of COPD (the BOLD
Study): a population-based prevalence study. Lancet 370, 741–750 (2007).
6. Wang, C. et al. Prevalence and risk factors of chronic obstructive pulmonary
disease in China (the China Pulmonary Health [CPH] study): a national cross-
sectional study. Lancet 391, 1706–1717 (2018).
7. Rodriguez-Roisin, R. Toward a consensus definition for COPD exacerbations. Chest
117, 398S–401S (2000).
8. Celli, B. R. & Barnes, P. J. Exacerbations of chronic obstructive pulmonary disease.
Eur. Respir. J. 29, 1224–1238 (2007).
9. Burge, S. & Wedzicha, J. A. COPD exacerbations: definitions and classifications.
Eur. Respir. J. Supple 41, 46s–53s (2003).
10. Vogelmeier, C. F. et al. Global Strategy for the Diagnosis, Management, and
Prevention of Chronic Obstructive Lung Disease 2017 Report. GOLD Executive
Summary. Am. J. Respir. Crit. Care Med. 195, 557–582 (2017).
11. Wedzicha, J. A. & Seemungal, T. A. COPD exacerbations: defining their cause and
prevention. Lancet 370, 786–796 (2007).
12. Farid, M. N. & Frerichs, R. R. CSurvey 2.0. http://www .ph.ucla.edu/epi/csurvey.html
(2008).
13. Zheng, J.-P. et al. Effect of carbocisteine on acute exacerbation of chronic
obstructive pulmonary disease (PEACE Study): a randomised placebo-controlled
study. Lancet 371, 2013–2018 (2008).
ACKNOWLEDGEMENTS
This study is funded by the National Key R&D Program of China (Project number:
2016YFC1304300).
AUTHOR CONTRIBUTIONS
The study concept and design was conceived by C.W. and S.Z. Analysis will be
performed by Z.P., Y.S., and S.W. Z.P. prepared the first draft of the manuscript. Y.C.,
T.Y., and K.H. provided expert clinical advice, Y.Z. and Y.H. provided expert advice on
research scheme and EDC system. All authors read and approved the final
manuscript.
COMPETING INTERESTS
The authors declare no competing interests.
ADDITIONAL INFORMATION
Supplementary information is available for this paper at https://doi.org/10.1038/
s41533-020-0186-y.
Correspondence and requests for materials should be addressed to S.Z.
Table 2. Steering committee of the ACURE study.
Center Province/city Principal investigator/coordinator
Peking University Third University Beijing Yahong Chen, MD
Chinese PLA General Hospital Beijing Junchang Cui, MD
Peking Union Medical College Hospital Beijing Jinglan Wang, MD
Beijing Hospital Beijing Chun Pu, MSc
The Second Hospital of Hebei Medical University Hebei Xixin Yan, MD
The First Affiliated Hospital of Chongqing Medical University Chongqing Shuliang Guo, MD
West China Hospital Sichuan University Sichuan He Yu, MSc
Changhai Hospital Shanghai Yuchao Dong, MD
The Second Affiliated Hospital of Chongqing Medical University Chongqing Daoxin Wang, MD
The First Hospital of China Medical University Liaoning Hongwen Zhao, MD
General Hospital of East China Jiangsu Xiaoyong Xu, MD
China-Japan Friendship Hospital Beijing Ting Yang, MD
ACURE estimating mortality among inpatients with Acute exacerbation of Chronic obstrUctive pulmonary disease using REgistry data, PLA People’s
Liberation Army.
Z. Pei et al.
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Published in partnership with Primary Care Respiratory Society UK npj Primary Care Respiratory Medicine (2020) 28
... gov identifier: NCT02657525). 15 The enrolment of participants began on 1 September 2017, and the study expected to recruit 7600 patients with a 3-year follow-up. The ACURE study adopted a multistage, stratified and cluster sampling method to recruit hospitals from mainland China. ...
... Details of the ACURE study have been previously described. 15 The eligibility criteria for the ACURE study were (1) aged ≥18 years, (2) confirmed or suspected hospitalisation for AECOPD, (3) not participating in other clinical trials or interventional studies and (4) signed consent for participation. Following the criteria in the guideline endorsed by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) scientific committee, AECOPD is defined as spirometry-confirmed COPD (a postbronchodilator ratio of forced expiratory volume in 1 s (FEV 1 ) to forced vital capacity (<0.70) with acute exacerbations of respiratory symptoms requiring additional treatment. ...
Developing and validating prediction models for severe exacerbations and readmissions in patients hospitalised for COPD exacerbation (SERCO) in China: a prospective observational study
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Background There is a lack of individualised prediction models for patients hospitalised with chronic obstructive pulmonary disease (COPD) for clinical practice. We developed and validated prediction models of severe exacerbations and readmissions in patients hospitalised for COPD exacerbation (SERCO). Methods Data were obtained from the Acute Exacerbations of Chronic Obstructive Pulmonary Disease Inpatient Registry study ( NCT02657525 ) in China. Cause-specific hazard models were used to estimate coefficients. C-statistic was used to evaluate the discrimination. Slope and intercept were used to evaluate the calibration and used for model adjustment. Models were validated internally by 10-fold cross-validation and externally using data from different regions. Risk-stratified scoring scales and nomograms were provided. The discrimination ability of the SERCO model was compared with the exacerbation history in the previous year. Results Two sets with 2196 and 1869 patients from different geographical regions were used for model development and external validation. The 12-month severe exacerbations cumulative incidence rates were 11.55% (95% CI 10.06% to 13.16%) in development cohorts and 12.30% (95% CI 10.67% to 14.05%) in validation cohorts. The COPD-specific readmission incidence rates were 11.31% (95% CI 9.83% to 12.91%) and 12.26% (95% CI 10.63% to 14.02%), respectively. Demographic characteristics, medical history, comorbidities, drug usage, Global Initiative for Chronic Obstructive Lung Disease stage and interactions were included as predictors. C-indexes for severe exacerbations were 77.3 (95% CI 70.7 to 83.9), 76.5 (95% CI 72.6 to 80.4) and 74.7 (95% CI 71.2 to 78.2) at 1, 6 and 12 months. The corresponding values for readmissions were 77.1 (95% CI 70.1 to 84.0), 76.3 (95% CI 72.3 to 80.4) and 74.5 (95% CI 71.0 to 78.0). The SERCO model was consistently discriminative and accurate with C-indexes in the derivation and internal validation groups. In external validation, the C-indexes were relatively lower at 60–70 levels. The SERCO model discriminated outcomes better than prior severe exacerbation history. The slope and intercept after adjustment showed close agreement between predicted and observed risks. However, in external validation, the models may overestimate the risk in higher-risk groups. The model-driven risk groups showed significant disparities in prognosis. Conclusion The SERCO model provides individual predictions for severe exacerbation and COPD-specific readmission risk, which enables identifying high-risk patients and implementing personalised preventive intervention for patients with COPD.
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... To address the knowledge gaps about clinical outcomes associated with pre-COPD in the Chinese population, we analysed data from the AEs of COPD Inpatient Registry (ACURE) study, in which a large sample of adults from 179 hospitals dispersed over 28 provinces were collected and represented the major Chinese AE of COPD (AECOPD) population. 17 To determine the basic characteristics of pre-COPD patients, the present study aimed to detect the clinical outcomes of pre-COPD, including respiratory-related and cardiovascular-related readmission and mortality, compared with the COPD population. ...
... Details regarding the study protocol have been described elsewhere. 17 The ACURE study began enrolling participants on 1 September 2017 and expects to recruit 7600 patients with a 3-year follow-up period. ...
Mortality and readmission risk for hospitalised patients with acute exacerbation of COPD with and without spirometric obstruction: a longitudinal observational study in China
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Objective To compare the clinical features and outcomes in patients with pre-chronic obstructive pulmonary disease (COPD) and COPD hospitalised for confirmed or suspected acute exacerbation of COPD (AECOPD). Design A multicentre, longitudinal observational cohort study. Setting Data were obtained from the AECOPD Inpatient Registry Study in China. Participants 5896 patients hospitalised for AECOPD between 2017 and 2021. Outcomes Patients were divided into the COPD (n=5201) and pre-COPD (n=695) groups according to the lung function test results. The outcomes of interest included all-cause, respiratory disease-related and cardiovascular disease-related deaths as well as readmissions within 30 days and 12 months after discharge. Cumulative incidence functions were used to estimate the risk of cause-specific mortality and readmission. Multivariate hazard function models were used to determine the association between lung function and outcomes. Results There were significant between-group differences in the symptoms at admission and medication use during hospitalisation. However, there was no significant between-group difference in the 30-day all-cause mortality (0.00 vs 2.23/1000 person-month (pm), p=0.6110) and readmission (33.52 vs 30.64/1000 pm, p=0.7175). Likewise, the 30-day and 12-month cause-specific outcomes were not significantly different between groups (30-day readmission with acute exacerbation (AE): 26.07 vs 25.11/1000 pm; 12-month all-cause mortality: 0.20 vs 0.93/1000 pm; all-cause readmission: 11.49 vs 13.75/1000 pm; readmission with AE: 9.15 vs 11.64/1000 pm, p>0.05 for all comparisons). Cumulative incidence curves revealed no significant between-group differences in the 30-day and 12-month prognosis (p>0.05). Multivariate analysis revealed no significant association of lung function categories with 30-day and 12-month mortality or readmission (p>0.05 for all effect estimations). Conclusions Patients with pre-COPD have mild symptoms and similar risks for mortality and readmission during follow-up as patients with COPD. Patients with pre-COPD should receive optimal therapies before the occurrence of irreversible damage.
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... When complications of AECOPD such as pulmonary hypertension, carbon dioxide retention (decreased alertness), hemodynamic instability, or arrhythmia develop, patients must be hospitalized [5]. The severity and frequency of exacerbations are strongly associated with mortality [6]. ...
Prognostic Significance of Thrombocytopenia and Mean Platelet Volume in COPD Patients with Acute Exacerbations in ICU Settings
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  • MED SCI MONITOR
Background Platelets have important modulatory effects on inflammatory and immune-mediated pathways. Thrombocytopenia is a critical condition that is frequently encountered in the intensive care unit (ICU) and increases mortality. This retrospective study of 472 patients admitted to the ICU with acute exacerbation of chronic obstructive pulmonary disease (COPD) aimed to evaluate thrombocytopenia and mean platelet volume (MPV) with prognosis and patient mortality. Material/Methods A total of 472 patients diagnosed with COPD according to GOLD criteria and hospitalized in the tertiary ICU between 1 April 2018 and 11 May 2021 were included in the study. Platelets were calculated by the impetance method and MPV was simultaneously calculated based on the platelet histogram. Patients with platelet count ≤100×10⁹/L and >100×10⁹/L and patients with MPV values <7 fl, 7–11 fl, and >11fl were compared in terms of mortality and prognosis. Results The mortality rate in COPD patients with thrombocytopenia was high, at 61.5%. Thrombocytopenia (P=.002), high MPV (P=.006) Acute Physiology and Chronic Health Evaluation-2 (APACHE-II) score (P=.025), length of stay (LOS) in the ICU (P=.009), mechanical ventilation duration (P<.001), leukocytosis (P<.001), high Sequential Organ Failure Assessment (SOFA) score (P<.001), LOS in the hospital (P=.035), and hypoalbuminemia (P<.001) were significantly associated with mortality. Conclusions Thrombocytopenia, high MPV, high APACHE-II and SOFA scores, LOS in the ICU and hospital, duration of mechanical ventilation, leukocytosis, and hypoalbuminemia predict mortality in COPD patients. Since infection-sepsis, hypoalbuminemia, and hypoxia can worsen this situation, ensuring early infection control, providing albumin support, and preventing hypoxia contribute significantly to reducing thrombocytopenia and mortality.
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... The details of the ACURE study have previously been described. 18 The eligibility criteria for the ACURE study were: (1) aged⩾18 years, (2) hospitalization for AECOPD, and (3) signed consent for participation. Patients who lost to follow-up 30 days and 6 months after discharge and those who did not have medication records were excluded. ...
Associations of medication regimen complexity with medication adherence and clinical outcomes in patients with chronic obstructive pulmonary disease: a prospective study
Article
Full-text available
Background High medication burdens are common in patients with chronic obstructive pulmonary disease (COPD). This study aimed to explore the associations of medication regimen complexity index (MRCI) with medication adherence and clinical outcomes among patients with acute exacerbations of COPD (AECOPD) after hospital discharge. Methods Data were obtained from a nationwide cohort study of inpatients with AECOPD in China. MRCI scores were calculated using the medication list 30 days after discharge and separated into COPD-specific and non-COPD MRCI scores. Medication adherence was measured by the withdrawal rate of COPD or inhaled long-acting bronchodilators 6 months after discharge. Clinical outcomes included re-exacerbations and COPD-related readmissions during the 30-day to 6-month follow-up period. The associations of MRCI with medication withdrawal and clinical outcomes were evaluated using univariate and multivariate logistic regressions. Potential covariates included sociodemographic factors, year of COPD diagnosis, post-bronchodilator percentage predicted forced expiratory volume in 1 s, mMRC score, CAT score, and comorbidities. Results Among the 2853 patients included, the median total MRCI score was 7 [interquartile range (IQR), 7−13]. A high MRCI score (>7) was presented in 1316 patients (46.1%). Of the MRCI score, 91% were COPD specific. The withdrawal rates of the COPD and inhaled long-acting bronchodilators were 24.2% and 24.4%, respectively. Re-exacerbation and COPD-related readmission rates were 10.2% and 7.5%, respectively. After adjusting for covariates, patients with high total MRCI scores were less likely to discontinue COPD drugs [odds ratio (OR), 0.62; 95% confidence interval (CI), 0.52−0.74] and inhaled long-acting bronchodilators (OR, 0.68; 95%CI, 0.57−0.81); conversely, these patients were more likely to experience re-exacerbation (OR, 1.64; 95% CI, 1.27−2.11) and readmission (OR, 1.57; 95% CI, 1.17−2.10). Conclusion MRCI scores were relatively low among post-hospitalized patients with AECOPD in China. Higher MRCI scores were positively associated with adherence to COPD or inhaled medications, and risk of re-exacerbation and readmission. Registration ClinicalTrials.gov identifier: NCT02657525.
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... Further details regarding ACURE have been described previously. 19 The present analysis included the data of patients enrolled until November 2021. The eligibility criteria were as follows: (1) age ≥18 years, (2) hospitalisation for confirmed diagnosis of ECOPD and (3) provided written informed consent for participation. ...
Re-exacerbation within 30 days of discharge is associated with poor prognosis in the following year among patients hospitalised with exacerbation of chronic obstructive pulmonary disease: a clinical cohort study
Article
Full-text available
  • Aug 2023
Background Exacerbation of chronic obstructive pulmonary disease (ECOPD) is a complex phenomenon, with marked heterogeneity in the aetiology, pathophysiology and clinical manifestations. This study aimed to evaluate the clinical characteristics and long-term outcomes of patients with 30-day exacerbation among those hospitalised with ECOPD in China. Methods Data from the Acute Exacerbations of Chronic Obstructive Pulmonary Disease Inpatient Registry were used in this study. The patients were divided into re-event and non-event groups based on the incidence of re-exacerbation within 30 days of discharge. Exacerbation, severe exacerbation and all-cause readmissions in the following 12 months were the outcomes of interest. The cumulative incidence rates and incidence densities were calculated. Multivariate hazard function models were used to determine the association between 30-day re-exacerbation and the long-term outcomes after accounting for the competing risk of death. Results Re-exacerbation within 30 days of discharge was observed in 4.9% (n=242) of the patients (n=4963). The cumulative incidence rates and incidence densities of exacerbation, severe exacerbation and all-cause readmissions in the event group were significantly higher than those in the non-event group. After adjustment, re-exacerbation within 30 days of discharge was associated with increased risks of exacerbation, severe exacerbation and all-cause readmissions in the following 12 months (adjusted HR: 3.85 (95% CI: 3.09 to 4.80), 3.46 (2.66 to 4.50) and 3.28 (2.52 to 4.25) accordingly). Conclusion Re-exacerbation of COPD within 30 days of discharge is a significant predictor of long-term prognosis. In clinical practice, short-term re-exacerbation is a significant clinical phenotype of ECOPD that requires careful management at the earliest.
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... At present, a registration study has been carried out in China to obtain real-world data on the clinical management of COPD after hospitalization and discharge, 23 and a study has also been conducted on the early-warning model of AECOPD. 27 Recently, a valid COPD Exacerbation Recognition Tool (CERT) is developed to provide patients with simple-to-follow guidance about when to seek medical services when their respiratory symptoms worsen. 28 It aims to help patients in all GOLD groups recognize moderate and severe exacerbations. ...
Early detection and prediction of acute exacerbation of chronic obstructive pulmonary disease
Article
Full-text available
  • Jun 2023
Chronic Obstructive Pulmonary Disease (COPD) is characterized by persistent respiratory symptoms and airflow limitation. Acute exacerbation of COPD (AECOPD) is an acute worsening of respiratory symptoms, which needs additional treatment and can result in worsening health status, increasing risks of hospitalization and mortality. Therefore, it is necessary to early recognize and diagnose exacerbations of COPD. This review introduces the updated definition of COPD exacerbations, the current clinical assessment tools, and the current potential biomarkers. The application of mobile health care in COPD management for early identification and diagnosis is also included in this review.
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... It started on 1 September 2017 and planned to recruit 7600 in-hospital AECOPD patients with a 3-year follow-up. The protocol and phase 1 results of the registry have been previously described (Pei et al., 2020;Liang et al., 2021). The study was approved by the ethics committee of China-Japan Friendship Hospital (No. 2015-88) and informed consent was obtained from all involved participants. ...
Better response to Tanreqing injection in frequent acute exacerbation of chronic obstructive pulmonary disease (AECOPD) patients—Real-world evidence from a nationwide registry (ACURE) study
Article
Full-text available
  • Mar 2023
Objective: Our aim was to systematically investigate the efficacy of Tanreqing (TRQ) injection on in-hospital outcomes among inpatients with frequent or infrequent AECOPD. Methods: In this ongoing, nationwide multicenter registry designed to investigate clinical characteristics, management, and prognoses of Chinese patients admitted for AECOPD in real-world settings, we collected characteristics, comorbidities, in-hospital prognoses, and information on the COPD assessment test (CAT) questionnaire, PEACE questionnaire, and modified British Medical Research Council (mMRC) questionnaire from each enrolled patient. Frequent AECOPD was determined as being admitted to the hospital ≥1 time or visiting the emergency room (ER) ≥ 2 times due to AECOPD within a year. A propensity match method and univariable and multivariable regression models were performed to analyze the efficacy of TRQ on clinical outcomes for inpatients with frequent AECOPD. Results: A total of 4135 inpatients were involved in the analysis, including 868 administered with TRQ and 3267 not administered with TRQ. After propensity score match, among those administered with TRQ, 493 had frequent AECOPD and 358 had infrequent AECOPD. A significant reduction of CAT score at discharge (TRQ median 12, IQR 8.0–16.0; non-TRQ median 13, IQR 9.0–18.0, p = 0.0297), a lower rate of ICU admission (TRQ 0.8% vs. non-TRQ 2.6%, p = 0.0191), and a shorter length of stay (LOS) (TRQ median 11, IQR 9.0–14.0; non-TRQ median 11, IQR 8.0–14.0, p = 0.004) were observed in the TRQ group, compared with the non-TRQ group among frequent AECOPD patients. In the subgroup analysis, for those with a PEACE score >7 on admission, TRQ contributed to a significantly lower CAT score at discharge (p = 0.0084) and a numerically lower ICU admission rate with a marginal statistical significance. Among those with phlegm-heat symptom complex on admission ≥2, a lower CAT score at discharge and a lower ICU admission were also observed in the TRQ group. Conclusion: TRQ injection had better efficacy in patients with frequent AECOPD in reducing ICU admission and alleviating respiratory symptoms, especially for those with higher severity on admission or more phlegm-heat symptoms.
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Influenza and pneumococcal vaccination coverage and associated factors in patients hospitalized with acute exacerbations of COPD in China: Findings from the real-world data
Article
Full-text available
  • Jul 2023
  • CHINESE MED J-PEKING
Background: Influenza and pneumococcal vaccination are a priority in patients with chronic obstructive pulmonary disease (COPD). However, limited information is available on vaccination coverage among patients with acute exacerbations of COPD (AECOPD) in China. This study aimed to determine the rates and associated factors of influenza and pneumococcal vaccination in patients hospitalized with AECOPD. Methods: Baseline data from a national, multicenter, hospital-based study that included adult inpatients with AECOPD between 2017 and 2021 were analyzed. The outcomes of interest were the influenza vaccination in the past year and the pneumococcal vaccination in the past 5 years. To ensure national representativeness, rates were weighted according to the distribution of hospital levels and types enrolled in this study. Multivariable Poisson regression based on mixed-effects models were used to determine the associated factors. The independent variables included the region and hospital features where the participants were located, sociodemographic characteristics (age, sex, rural/urban residence, education, etc.), and clinical indicators (COPD disease history, lung function parameters, comorbidities, etc.). The treatment profiles of the vaccinated and unvaccinated participants were compared. Results: Of 6949 eligible participants, the weighted rates of influenza/pneumococcal, influenza, and pneumococcal vaccination were 2.72% (95% confidence interval [CI]: 2.34-3.10%), 2.09% (95% CI: 1.76-2.43%), and 1.25% (95% CI: 0.99-1.51%), respectively. In multivariable models, age ≥60 years (60-69 years, odds ratio [OR]: 1.90, 95% CI: 1.11-3.25; ≥80 years, OR: 2.00, 95% CI: 1.06-3.78), geographical regions (Northern China relative to Eastern China, OR: 5.09, 95% CI: 1.96-13.21), urban residence (OR: 1.69, 95% CI: 1.07-2.66), a higher education level (junior high school, OR: 1.77, 95% CI: 1.21-2.58; senior high school or above, OR: 2.61, 95% CI: 1.69-4.03), former smoking (OR: 1.79, 95% CI: 1.15-2.79), and regular inhaled medication treatment (OR: 3.28, 95% CI: 2.29-4.70) were positively associated with vaccination. Patients who had experienced severe exacerbations in the past year were less likely to be vaccinated (OR: 0.65, 95% CI: 0.45-0.96). Compared with unvaccinated participants, vaccinated participants adhered better to pharmacological and non-pharmacological treatment. Conclusions: Influenza and pneumococcal vaccination coverage are extremely low. Urgent measures are necessary to increase vaccination coverage among inpatients with AECOPD in China.
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Development of a machine learning-based nomogram for predicting one-year mortality in elderly patients with chronic obstructive pulmonary disease in intensive care unit
Preprint
Full-text available
  • Nov 2022
Objective: Predictors of one-year mortality for elderly patients referred to intensive care units (ICUs) with chronic obstructive pulmonary disease (COPD) remain poorly described. We sought to create and verify a model for predicting all-cause one-year death among COPD patients admitted to the ICU. Methods: A retrospective cohort study was designed. The Medical Information Mart for Intensive Care (MIMIC-IV) database was mined for information. A total of 2313 patients with COPD who met the inclusion criteria were screened for eligibility using registry data from the MIMIC-IV database between January 2008 and December 2019, which was randomized into training (n = 1628, 70%) and testing groups (n = 685, 30%). The tree model-based extreme gradient boosting (XGBoost), random forest (RF), and lightGBM algorithms were used in the training samples to rank feature importance and screen out its top 10 union features as independent mortality risk factors.The variance inflation factor (VIF) was used to check for collinearity in the prediction model's input variables, and multivariate logistic regression analysis was used to take a gander at factors related to mortality and then to use those factors to create a nomogram for predicting prognosis, which was then tested on the testing cohort. The AUC, calibration plot, and decision curve analysis were performed to evaluate the predictive model's discrimination, calibration, and clinical utility. Results: The results showed that ∼40.60% (939 out of 2,313) of the patients died. In multivariate logistic regression analyses, weight, BUN, RDW, MCHC, age, malignancy, and heart_rate were all independent predictors of mortality. In both groups, the nomogram showed acceptable discrimination (area under curve [AUC] = 0.7216 [95% confidence interval (CI) 0.6968–0.7465] and AUC=0.7481 [95% CI 0.7116–0.7845], respectively) and good calibration compared to SOFA, SAPS II, LODS, APS III, OASIS, SIRS, GCS, and MELD risk scores.In addition, it was discovered that calibration plots accurately predicted one-year mortality. The examination of decision curves (DCAs) revealed that the nomogram model had a greater net benefit. Conclusions: Our nomogram provides interpretable and visual explanations of customized one-year death projections in ICU-admitted elderly patients with COPD, which may aid clinical clinicians in comprehending the effects of key model characteristics and the model's decision-making for such patients.
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Global, regional, and national deaths, prevalence, disability-adjusted life years, and years lived with disability for chronic obstructive pulmonary disease and asthma, 1990-2015: A systematic analysis for the Global Burden of Disease Study 2015
Article
Full-text available
  • Sep 2017
Background: Chronic obstructive pulmonary disease (COPD) and asthma are common diseases with a heterogeneous distribution worldwide. Here, we present methods and disease and risk estimates for COPD and asthma from the Global Burden of Diseases, Injuries, and Risk Factors (GBD) 2015 study. The GBD study provides annual updates on estimates of deaths, prevalence, and disability-adjusted life years (DALYs), a summary measure of fatal and non-fatal disease outcomes, for over 300 diseases and injuries, for 188 countries from 1990 to the most recent year. Methods: We estimated numbers of deaths due to COPD and asthma using the GBD Cause of Death Ensemble modelling (CODEm) tool. First, we analysed data from vital registration and verbal autopsy for the aggregate category of all chronic respiratory diseases. Subsequently, models were run for asthma and COPD relying on covariates to predict rates in countries that have incomplete or no vital registration data. Disease estimates for COPD and asthma were based on systematic reviews of published papers, unpublished reports, surveys, and health service encounter data from the USA. We used the Global Initiative of Chronic Obstructive Lung Disease spirometry-based definition as the reference for COPD and a reported diagnosis of asthma with current wheeze as the definition of asthma. We used a Bayesian meta-regression tool, DisMod-MR 2.1, to derive estimates of prevalence and incidence. We estimated population-attributable fractions for risk factors for COPD and asthma from exposure data, relative risks, and a theoretical minimum exposure level. Results were stratified by Socio-demographic Index (SDI), a composite measure of income per capita, mean years of education over the age of 15 years, and total fertility rate. Findings: In 2015, 3·2 million people (95% uncertainty interval [UI] 3·1 million to 3·3 million) died from COPD worldwide, an increase of 11·6% (95% UI 5·3 to 19·8) compared with 1990. There was a decrease in age-standardised death rate of 41·9% (37·7 to 45·1) but this was counteracted by population growth and ageing of the global population. From 1990 to 2015, the prevalence of COPD increased by 44·2% (41·7 to 46·6), whereas age-standardised prevalence decreased by 14·7% (13·5 to 15·9). In 2015, 0·40 million people (0·36 million to 0·44 million) died from asthma, a decrease of 26·7% (-7·2 to 43·7) from 1990, and the age-standardised death rate decreased by 58·8% (39·0 to 69·0). The prevalence of asthma increased by 12·6% (9·0 to 16·4), whereas the age-standardised prevalence decreased by 17·7% (15·1 to 19·9). Age-standardised DALY rates due to COPD increased until the middle range of the SDI before reducing sharply. Age-standardised DALY rates due to asthma in both sexes decreased monotonically with rising SDI. The relation between with SDI and DALY rates due to asthma was attributed to variation in years of life lost (YLLs), whereas DALY rates due to COPD varied similarly for YLLs and years lived with disability across the SDI continuum. Smoking and ambient particulate matter were the main risk factors for COPD followed by household air pollution, occupational particulates, ozone, and secondhand smoke. Together, these risks explained 73·3% (95% UI 65·8 to 80·1) of DALYs due to COPD. Smoking and occupational asthmagens were the only risks quantified for asthma in GBD, accounting for 16·5% (14·6 to 18·7) of DALYs due to asthma. Interpretation: Asthma was the most prevalent chronic respiratory disease worldwide in 2015, with twice the number of cases of COPD. Deaths from COPD were eight times more common than deaths from asthma. In 2015, COPD caused 2·6% of global DALYs and asthma 1·1% of global DALYs. Although there are laudable international collaborative efforts to make surveys of asthma and COPD more comparable, no consensus exists on case definitions and how to measure disease severity for population health measurements like GBD. Comparisons between countries and over time are important, as much of the chronic respiratory burden is either preventable or treatable with affordable interventions. Funding: Bill & Melinda Gates Foundation.
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Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 Report: GOLD Executive Summary
Article
Full-text available
  • Jan 2017
  • AM J RESP CRIT CARE
This Executive Summary of the Global Strategy for the Diagnosis, Management, and Prevention of COPD (GOLD) 2017 Report focuses primarily on the revised and novel parts of the document. The most significant changes include: i) the assessment of COPD has been refined to separate the spirometric assessment from symptom evaluation. ABCD groups are now proposed to be derived exclusively from patient symptoms and their history of exacerbations; ii) for each of the groups A to D, escalation strategies for pharmacological treatments are proposed; iii) the concept of de-escalation of therapy is introduced in the treatment assessment scheme; iv) nonpharmacologic therapies are comprehensively presented and; v) the importance of comorbid conditions in managing COPD is reviewed.
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Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: A systematic analysis for the Global Burden of Disease Study 2010
Article
Full-text available
  • Dec 2012
Background: Reliable and timely information on the leading causes of death in populations, and how these are changing, is a crucial input into health policy debates. In the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010), we aimed to estimate annual deaths for the world and 21 regions between 1980 and 2010 for 235 causes, with uncertainty intervals (UIs), separately by age and sex. Methods: We attempted to identify all available data on causes of death for 187 countries from 1980 to 2010 from vital registration, verbal autopsy, mortality surveillance, censuses, surveys, hospitals, police records, and mortuaries. We assessed data quality for completeness, diagnostic accuracy, missing data, stochastic variations, and probable causes of death. We applied six different modelling strategies to estimate cause-specific mortality trends depending on the strength of the data. For 133 causes and three special aggregates we used the Cause of Death Ensemble model (CODEm) approach, which uses four families of statistical models testing a large set of different models using different permutations of covariates. Model ensembles were developed from these component models. We assessed model performance with rigorous out-of-sample testing of prediction error and the validity of 95% UIs. For 13 causes with low observed numbers of deaths, we developed negative binomial models with plausible covariates. For 27 causes for which death is rare, we modelled the higher level cause in the cause hierarchy of the GBD 2010 and then allocated deaths across component causes proportionately, estimated from all available data in the database. For selected causes (African trypanosomiasis, congenital syphilis, whooping cough, measles, typhoid and parathyroid, leishmaniasis, acute hepatitis E, and HIV/AIDS), we used natural history models based on information on incidence, prevalence, and case-fatality. We separately estimated cause fractions by aetiology for diarrhoea, lower respiratory infections, and meningitis, as well as disaggregations by subcause for chronic kidney disease, maternal disorders, cirrhosis, and liver cancer. For deaths due to collective violence and natural disasters, we used mortality shock regressions. For every cause, we estimated 95% UIs that captured both parameter estimation uncertainty and uncertainty due to model specification where CODEm was used. We constrained cause-specific fractions within every age-sex group to sum to total mortality based on draws from the uncertainty distributions. Findings: In 2010, there were 52·8 million deaths globally. At the most aggregate level, communicable, maternal, neonatal, and nutritional causes were 24·9% of deaths worldwide in 2010, down from 15·9 million (34·1%) of 46·5 million in 1990. This decrease was largely due to decreases in mortality from diarrhoeal disease (from 2·5 to 1·4 million), lower respiratory infections (from 3·4 to 2·8 million), neonatal disorders (from 3·1 to 2·2 million), measles (from 0·63 to 0·13 million), and tetanus (from 0·27 to 0·06 million). Deaths from HIV/AIDS increased from 0·30 million in 1990 to 1·5 million in 2010, reaching a peak of 1·7 million in 2006. Malaria mortality also rose by an estimated 19·9% since 1990 to 1·17 million deaths in 2010. Tuberculosis killed 1·2 million people in 2010. Deaths from non-communicable diseases rose by just under 8 million between 1990 and 2010, accounting for two of every three deaths (34·5 million) worldwide by 2010. 8 million people died from cancer in 2010, 38% more than two decades ago; of these, 1·5 million (19%) were from trachea, bronchus, and lung cancer. Ischaemic heart disease and stroke collectively killed 12·9 million people in 2010, or one in four deaths worldwide, compared with one in five in 1990; 1·3 million deaths were due to diabetes, twice as many as in 1990. The fraction of global deaths due to injuries (5·1 million deaths) was marginally higher in 2010 (9·6%) compared with two decades earlier (8·8%). This was driven by a 46% rise in deaths worldwide due to road traffic accidents (1·3 million in 2010) and a rise in deaths from falls. Ischaemic heart disease, stroke, chronic obstructive pulmonary disease (COPD), lower respiratory infections, lung cancer, and HIV/AIDS were the leading causes of death in 2010. Ischaemic heart disease, lower respiratory infections, stroke, diarrhoeal disease, malaria, and HIV/AIDS were the leading causes of years of life lost due to premature mortality (YLLs) in 2010, similar to what was estimated for 1990, except for HIV/AIDS and preterm birth complications. YLLs from lower respiratory infections and diarrhoea decreased by 45-54% since 1990; ischaemic heart disease and stroke YLLs increased by 17-28%. Regional variations in leading causes of death were substantial. Communicable, maternal, neonatal, and nutritional causes still accounted for 76% of premature mortality in sub-Saharan Africa in 2010. Age standardised death rates from some key disorders rose (HIV/AIDS, Alzheimer's disease, diabetes mellitus, and chronic kidney disease in particular), but for most diseases, death rates fell in the past two decades; including major vascular diseases, COPD, most forms of cancer, liver cirrhosis, and maternal disorders. For other conditions, notably malaria, prostate cancer, and injuries, little change was noted. Conclusions: Population growth, increased average age of the world's population, and largely decreasing age-specific, sex-specific, and cause-specific death rates combine to drive a broad shift from communicable, maternal, neonatal, and nutritional causes towards non-communicable diseases. Nevertheless, communicable, maternal, neonatal, and nutritional causes remain the dominant causes of YLLs in sub-Saharan Africa. Overlaid on this general pattern of the epidemiological transition, marked regional variation exists in many causes, such as interpersonal violence, suicide, liver cancer, diabetes, cirrhosis, Chagas disease, African trypanosomiasis, melanoma, and others. Regional heterogeneity highlights the importance of sound epidemiological assessments of the causes of death on a regular basis. Funding: Bill & Melinda Gates Foundation.
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Prevalence and risk factors of chronic obstructive pulmonary disease in China (the China Pulmonary Health [CPH] study): a national cross-sectional study
Article
  • Apr 2018
Background: Although exposure to cigarette smoking and air pollution is common, the current prevalence of chronic obstructive pulmonary disease (COPD) is unknown in the Chinese adult population. We conducted the China Pulmonary Health (CPH) study to assess the prevalence and risk factors of COPD in China. Methods: The CPH study is a cross-sectional study in a nationally representative sample of adults aged 20 years or older from ten provinces, autonomous regions, and municipalities in mainland China. All participants underwent a post-bronchodilator pulmonary function test. COPD was diagnosed according to 2017 Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria. Findings: Between June, 2012, and May, 2015, 57 779 individuals were invited to participate, of whom 50 991 (21 446 men and 29 545 women) had reliable post-bronchodilator results and were included in the final analysis. The overall prevalence of spirometry-defined COPD was 8·6% (95% CI 7·5-9·9), accounting for 99·9 (95% CI 76·3-135·7) million people with COPD in China. Prevalence was higher in men (11·9%, 95% CI 10·2-13·8) than in women (5·4%, 4·6-6·2; p<0·0001 for sex difference) and in people aged 40 years or older (13·7%, 12·1-15·5) than in those aged 20-39 years (2·1%, 1·4-3·2; p<0·0001 for age difference). Only 12·0% (95% CI 8·1-17·4) of people with COPD reported a previous pulmonary function test. Risk factors for COPD included smoking exposure of 20 pack-years or more (odds ratio [OR] 1·95, 95% CI 1·53-2·47), exposure to annual mean particulate matter with a diameter less than 2·5 μm of 50-74 μg/m3 (1·85, 1·23-2·77) or 75 μg/m3 or higher (2·00, 1·36-2·92), underweight (body-mass index <18·5 kg/m2; 1·43, 1·03-1·97), sometimes childhood chronic cough (1·48, 1·14-1·93) or frequent cough (2·57, 2·01-3·29), and parental history of respiratory diseases (1·40, 1·23-1·60). A lower risk of COPD was associated with middle or high school education (OR 0·76, 95% CI 0·64-0·90) and college or higher education (0·47, 0·33-0·66). Interpretation: Spirometry-defined COPD is highly prevalent in the Chinese adult population. Cigarette smoking, ambient air pollution, underweight, childhood chronic cough, parental history of respiratory diseases, and low education are major risk factors for COPD. Prevention and early detection of COPD using spirometry should be a public health priority in China to reduce COPD-related morbidity and mortality. Funding: Ministry of Health and Ministry of Science and Technology of China.
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Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 Report
Article
  • Feb 2017
This Executive Summary of the Global Strategy for the Diagnosis, Management, and Prevention of COPD (GOLD) 2017 Report focuses primarily on the revised and novel parts of the document. The most significant changes include: i) the assessment of COPD has been refined to separate the spirometric assessment from symptom evaluation. ABCD groups are now proposed to be derived exclusively from patient symptoms and their history of exacerbations; ii) for each of the groups A to D, escalation strategies for pharmacological treatments are proposed; iii) the concept of de-escalation of therapy is introduced in the treatment assessment scheme; iv) nonpharmacologic therapies are comprehensively presented and; v) the importance of comorbid conditions in managing COPD is reviewed.
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COPD in China The Burden and Importance of Proper Management
Article
  • Apr 2011
  • CHEST
Although, to our knowledge, there has been no exhaustive or credible review of the evidence of the disease burden of COPD in China, COPD has become an increasing public health concern to the Chinese medical community. The purpose of this article is to review the evidence and evaluate and clarify the disease burden of COPD in China with the aim of improving effective management. We reviewed previous studies of COPD in China, which included data on prevalence, mortality, disease burden, risk factors, diagnosis, and management by searching related Web sites, including PubMed, ProQuest, and Thomson Reuters' Web of Knowledge, as well as major Chinese databases and government Web sites. Reported COPD prevalence varied between 5% and 13% in different provinces/cities across China. In 2008, COPD ranked fourth as a leading cause of death in urban areas and third in rural areas. In addition, COPD accounted for 1.6% of all hospital admissions in China in that year. The high prevalence of smoking and biomass fuel use acted as major contributors to the high occurrence of COPD in China. Management of COPD in China should focus on adjusting the distribution of medical resources and on addressing public health policies to facilitate earlier diagnosis in rural areas, aim to reduce smoking prevalence, improve patients' self-management, and keep physicians' knowledge up to date and consistent with current guidelines. COPD is one of the most challenging medical issues facing China because of its influence on both personal and public health and its impact on the economy. Optimal management strategies should be adopted and strengthened immediately.
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Toward a Consensus Definition for COPD Exacerbations
Article
  • Jun 2000
In patients with COPD, an acute worsening of respiratory symptoms is often described as an exacerbation. Exacerbations are associated with a significant increase in mortality, hospitalization, and health-care utilization, but there is currently no widely accepted definition of what constitutes an exacerbation of COPD. This paper summarizes the discussions of the workshop, "COPD: Working Towards a Greater Understanding," in which the participants proposed the following working definition of an exacerbation of COPD: a sustained worsening of the patient's condition, from the stable state and beyond normal day-to-day variations, that is acute in onset and necessitates a change in regular medication in a patient with underlying COPD.
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Interpreting COPD prevalence estimates: What is the true burden of disease?
Article
  • Jun 2003
To summarize the available data on COPD prevalence and assess reasons for conflicting prevalence estimates in the published literature. We reviewed published studies that (1) estimated COPD prevalence for a population, and (2) clearly described the methods used to obtain the estimates. Thirty-two sources of COPD prevalence rates, representing 17 countries and eight World Health Organization-classified regions, were identified and reviewed. Prevalence estimates were based on spirometry (11 studies), respiratory symptoms (14 studies), patient-reported disease (10 studies), or expert opinion. Reported prevalence ranged from 0.23 to 18.3%. The lowest prevalence rates (0.2 to 2.5%) were based on expert opinion. Sixteen studies had measured rates that could reasonably be extrapolated to an entire region or country. All were for Europe or North America, and most fell between 4% and 10%. There is considerable variation in the reported prevalence of COPD. The overall prevalence in adults appears to lie between 4% and 10% in countries where it has been rigorously measured. Some of the variation attributed to differences in risk exposure or population characteristics may be influenced by the methods and definitions used to measure disease. Spirometry is least influenced by local diagnostic practice, but it is subject to variation based on the lung function parameters selected to define COPD.
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COPD exacerbations: Definitions and classifications
Article
  • Jul 2003
  • Eur Respir J Suppl
Chronic obstructive pulmonary disease (COPD) is defined independently of exacerbations, which are largely a feature of moderate-to-severe disease. This article is the result of a workshop that tried to define exacerbations of COPD for use in clinical, pharmacological and epidemiological studies. The conclusions represent the consensus of those present. This review describes definitions, ascertainment, severity assessments, duration and frequency, using varying sources of data including direct patient interview, healthcare databases and symptom diaries kept by patients in studies. The best general definition of a COPD exacerbation is the following: an exacerbation of COPD is a sustained worsening of the patient's condition, from the stable state and beyond normal day-to-day variations that is acute in onset and may warrant additional treatment in a patient with underlying COPD. A more specific definition for studies where a bacteriological cause of exacerbation is being studied is included, as well as simpler definitions for retrospective identification from database sources. Prospective diary card assessments are best recorded as changes from an agreed baseline, rather than absolute symptom severities. Diary cards identify many unreported exacerbations, which on average have similar severities to reported exacerbations. A scale for exacerbation severity is proposed that incorporates in- and outpatient assessments. Exacerbation duration, which also relates to severity, is defined from diary card reports. Healthcare utilisation is not an adequate substitute for severity, depending on many unrelated social and comorbidity factors. It is an outcome in its own right.
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Exacerbations of chronic obstructive pulmonary disease
Article
  • Jul 2007
Exacerbations of chronic obstructive pulmonary disease are of major importance in terms of their prolonged detrimental effects on patients, the acceleration in disease progression and high healthcare costs. There is still debate about how exacerbations should be defined and graded, and their mechanisms are poorly understood. The major causal agents are either bacteria or viral infections, or a combination of the two. Noninfective causes include air pollution and pulmonary embolus but, in some patients, no cause is identified. Exacerbations represent an increase in the inflammation that is present in the stable state, with increased numbers of inflammatory cells (particularly neutrophils), cytokines, chemokines and proteases in the airways, and increased concentrations of certain cytokines and C-reactive protein in the blood. There are presently no reliable biomarkers with which to predict exacerbations. Exacerbations have a long-lasting adverse influence on health status. High doses of bronchodilators are the mainstay of treatment and systemic corticosteroids have some benefit. The routine use of antibiotics remains controversial but they are of benefit with exacerbations of a bacterial origin. Noninvasive ventilation is beneficial in preventing the need for intubation and its important complications but it is not certain whether its use in stable patients prevents exacerbations. Although important advances have been made, more effective treatments are needed in the future for prevention and treatment of exacerbations.
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