268 results found
Buttery S, Lewis A, Kemp S, et al., Lung Volume Reduction eligibility in COPD patients attending Pulmonary Rehabilitation – results from the UK National Asthma and COPD Audit Programme, BMJ Open, ISSN: 2044-6055
Quint J, O'leary C, venerus A, et al., 2020, Prescribing Pathways to Triple Therapy: A Multi-Country, Retrospective Observational Study of Adult Patients with Chronic Obstructive Pulmonary Disease, Pulmonary Therapy, ISSN: 2364-1746
Drake TM, Docherty AB, Harrison EM, et al., 2020, Outcome of hospitalization for COVID-19 in patients with interstitial lung disease: an international multicenter study., American Journal of Respiratory and Critical Care Medicine, ISSN: 1073-449X
RATIONALE: The impact of COVID-19 on patients with Interstitial Lung Disease (ILD) has not been established. OBJECTIVES: To assess outcomes in patients with ILD hospitalized for COVID-19 versus those without ILD in a contemporaneous age, sex and comorbidity matched population. METHODS: An international multicenter audit of patients with a prior diagnosis of ILD admitted to hospital with COVID-19 between 1 March and 1 May 2020 was undertaken and compared with patients, without ILD obtained from the ISARIC 4C cohort, admitted with COVID-19 over the same period. The primary outcome was survival. Secondary analysis distinguished IPF from non-IPF ILD and used lung function to determine the greatest risks of death. MEASUREMENTS AND MAIN RESULTS: Data from 349 patients with ILD across Europe were included, of whom 161 were admitted to hospital with laboratory or clinical evidence of COVID-19 and eligible for propensity-score matching. Overall mortality was 49% (79/161) in patients with ILD with COVID-19. After matching ILD patients with COVID-19 had higher mortality (HR 1.60, Confidence Intervals 1.17-2.18 p=0.003) compared with age, sex and co-morbidity matched controls without ILD. Patients with a Forced Vital Capacity (FVC) of <80% had an increased risk of death versus patients with FVC ≥80% (HR 1.72, 1.05-2.83). Furthermore, obese patients with ILD had an elevated risk of death (HR 2.27, 1.39-3.71). CONCLUSIONS: Patients with ILD are at increased risk of death from COVID-19, particularly those with poor lung function and obesity. Stringent precautions should be taken to avoid COVID-19 in patients with ILD. This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License 4.0 (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Bloom CI, Cabrera C, Arnetorp S, et al., 2020, Asthma-related health outcomes associated with short-acting beta(2)-agonist inhaler use: an observational UK study as part of the SABINA global program, Advances in Therapy, Vol: 37, Pages: 4190-4208, ISSN: 0741-238X
IntroductionPatients with asthma typically increase short-acting β2-agonists (SABA) use with worsening symptoms. Excessive SABA use may lead to a higher risk of adverse outcomes. We evaluated, in a large population cohort, an association between SABA inhaler use and asthma exacerbations and healthcare utilization.MethodsAs part of the SABINA (SABA use IN Asthma) global program, we conducted a retrospective longitudinal observational study (SABINA I) using UK primary care electronic healthcare records (Clinical Practice Research Datalink; 2007–2017) from asthma patients aged ≥ 12 years. SABA inhaler use was classified as ‘high use ’ 3 canisters/year versus ‘low use’, 0–2 canisters/year. Taking into consideration all their asthma prescriptions, patients were categorized into a treatment step according to 2016 British Thoracic Society (BTS) asthma management guidelines. Multivariable regression assessed the association of SABA inhaler use by BTS treatment steps (grouped as BTS steps 1/2 and 3–5), separately, and with outcomes of exacerbations or asthma-related healthcare utilization (primary care and hospital outpatient consultations); only patients with linked hospital data were included in this analysis.ResultsOf the 574,913 patients included, 218,365 (38%) had high SABA inhaler use. Overall, 336,412 patients had linked hospital data. High SABA inhaler use was significantly associated with an increased risk of exacerbations [adjusted hazard ratio, 95% confidence interval (CI): BTS steps 1/2 = 1.20, 1.16–1.24; BTS steps 3–5 = 1.24, 1.20–1.28], asthma-related primary care consultations [adjusted incidence rate ratio (IRR), 95% CI: BTS steps 1/2 = 1.24, 1.23–1.26; BTS steps 3–5 = 1.13, 1.11–1.15), and asthma-related hospital outpatient consultations (adjusted IRR, 95% CI: BTS steps 1/2 = 1.19, 1.12&ndas
Axson E, Lewis A, Potts J, et al., 2020, Inhaled therapies for chronic obstructive pulmonary disease: a systematic review and meta-analysis, BMJ Open, Vol: 10, ISSN: 2044-6055
Objectives To integrate evidence from randomised controlled trials (RCTs) and observational studies on the efficacy of inhaled treatments for chronic obstructive pulmonary disease using network meta-analyses.Methods Systematic searches MEDLINE and Embase based on predetermined criteria. Network meta-analyses of RCTs investigated efficacy on exacerbations (long-term: ≥20 weeks of treatment; short-term: <20 weeks), lung function (≥12 weeks), health-related quality of life, mortality and adverse events. Qualitative comparisons of efficacies between RCTs and observational studies.Results 212 RCTs and 19 observational studies were included. Compared with combined long-acting beta-adrenoceptor agonists and long-acting muscarinic antagonists (LABA+LAMA), triple therapy (LABA+LAMA+inhaled corticosteroid) was significantly more effective at reducing exacerbations (long-term 0.85 (95% CI: 0.78 to 0.94; short-term 0.67 (95% CI: 0.49 to 0.92)) and mortality (0.72 (95% CI: 0.59 to 0.89)) but was also associated with increased pneumonia (1.35 (95% CI: 1.10 to 1.67)). No differences in lung function (0.02 (95% CI: −0.10 to 0.14)), health-related quality of life (−1.12 (95% CI: −3.83 to 1.59)) or other adverse events (1.02 (95% CI: 0.96 to 1.08)) were found. Most of the observational evidence trended in the same direction as pooled RCT data.Conclusion Further evidence, especially pragmatic trials, are needed to fully understand the characteristics of patient subgroups who may benefit from triple therapy and for those whom the extra risk of adverse events, such as pneumonia, may outweigh any benefits.
wing K, williamson E, carpenter J, et al., Real world effects of COPD medications: a cohort study with validation against RCT results, European Respiratory Journal, ISSN: 0903-1936
Stone P, Quint J, Predictors of referral to pulmonary rehabilitation from UK primary care, International Journal of Chronic Obstructive Pulmonary Disease, ISSN: 1178-2005
Schultze A, Walker AJ, MacKenna B, et al., 2020, Risk of COVID-19-related death among patients with chronic obstructive pulmonary disease or asthma prescribed inhaled corticosteroids: an observational cohort study using the OpenSAFELY platform., Lancet Respir Med
BACKGROUND: Early descriptions of patients admitted to hospital during the COVID-19 pandemic showed a lower prevalence of asthma and chronic obstructive pulmonary disease (COPD) than would be expected for an acute respiratory disease like COVID-19, leading to speculation that inhaled corticosteroids (ICSs) might protect against infection with severe acute respiratory syndrome coronavirus 2 or the development of serious sequelae. We assessed the association between ICS and COVID-19-related death among people with COPD or asthma using linked electronic health records (EHRs) in England, UK. METHODS: In this observational study, we analysed patient-level data for people with COPD or asthma from primary care EHRs linked with death data from the Office of National Statistics using the OpenSAFELY platform. The index date (start of follow-up) for both cohorts was March 1, 2020; follow-up lasted until May 6, 2020. For the COPD cohort, individuals were eligible if they were aged 35 years or older, had COPD, were a current or former smoker, and were prescribed an ICS or long-acting β agonist plus long-acting muscarinic antagonist (LABA-LAMA) as combination therapy within the 4 months before the index date. For the asthma cohort, individuals were eligible if they were aged 18 years or older, had been diagnosed with asthma within 3 years of the index date, and were prescribed an ICS or short-acting β agonist (SABA) only within the 4 months before the index date. We compared the outcome of COVID-19-related death between people prescribed an ICS and those prescribed alternative respiratory medications: ICSs versus LABA-LAMA for the COPD cohort, and low-dose or medium-dose and high-dose ICSs versus SABAs only in the asthma cohort. We used Cox regression models to estimate hazard ratios (HRs) and 95% CIs for the association between exposure categories and the outcome in each population, adjusted for age, sex, and all other prespecified covariates. We calculated e-values to
Whittaker H, Bloom C, Morgan A, et al., 2020, Accelerated FEV1 decline and risk of cardiovascular disease and mortality in a primary care population of COPD patients, European Respiratory Journal, ISSN: 0903-1936
Accelerated lung function decline has been associated with increased risk of cardiovascular disease (CVD) in a general population, but little is known about this association in chronic obstructive pulmonary disease (COPD). We investigated the association between accelerated lung function decline and CVD outcomes and mortality in a primary care COPD population.COPD patients without a history of CVD were identified in the Clinical Practice Research Datalink (CPRD-GOLD) primary care dataset (n=36 282). Accelerated FEV1 decline was defined using the fastest quartile of the COPD population's decline. Cox regression assessed the association between baseline accelerated FEV1 decline and a composite CVD outcome over follow-up (myocardial infarction, ischaemic stroke, heart failure, atrial fibrillation, coronary artery disease, and CVD mortality). The model was adjusted for age, gender, smoking status, BMI, history of asthma, hypertension, diabetes, statin use, mMRC dyspnoea, exacerbation frequency, and baseline FEV1 percent predicted.6110 (16.8%) COPD patients had a CVD event during follow-up; median length of follow-up was 3.6 years [IQR 1.7–6.1]). Median rate of FEV1 decline was –19.4 mL·year−1 (IQR, –40.5 to 1.9); 9095 (25%) patients had accelerated FEV1 decline (>–40.5 mL·year−1), 27 287 (75%) did not (≤ –40.5 mL·year−1). Risk of CVD and mortality was similar between patients with and without accelerated FEV1 decline (HRadj 0.98 [95%CI, 0.90–1.06]). Corresponding risk estimates were 0.99 (95%CI 0.83–1.20) for heart failure, 0.89 (95%CI 0.70–1.12) for myocardial infarction, 1.01 (95%CI 0.82–1.23) for stroke, 0.97 (95%CI 0.81–1.15) for atrial fibrillation, 1.02 (95%CI 0.87–1.19) for coronary artery disease, and 0.94 (95%CI 0.71–1.25) for CVD mortality. Rather, risk of CVD was associated with mMRC score ≥2 and ≥2 exacerbations in the year prior.CVD out
Sinha I, Quint J, Roberts CM, 2020, Improving outcomes for children with asthma: the role of a national audit, Archives of Disease in Childhood, Vol: 105, Pages: 919-920, ISSN: 0003-9888
Schulze A, Walker A, MacKenna B, et al., Inhaled corticosteroid use and risk COVID-19 related death among 966,461 patients with COPD or asthma: an OpenSAFELY analysis, The Lancet Respiratory Medicine, ISSN: 2213-2600
Denaxas S, shah A, mateen B, et al., A semi-supervised approach for rapidly creating clinical biomarker phenotypes in the UK Biobank using different primary care EHR and clinical terminology systems, Jama Network Open, ISSN: 2574-3805
Background Large-scale population level electronic health records can enable researchers to monitor the impact of chronic conditions on patients, and the healthcare system, as well as providing a resource for rapidly responding to health emergencies such as the COVID-19 pandemic. The UK Biobank (UKB) is making primary care Electronic Health Records (EHR) for 500,000 participants available for COVID-19-related research. The data however are sourced from four different sources in England, Scotland and Wales, recorded using five different controlled clinical terminologies and recorded in different schemas. As a result, despite the urgent need to analyze these data and translate findings into actionable policy, researchers will need to spend a significant amount of time and effort to create useful phenotypes.ObjectivesThe aims of our research were to: a) develop and apply a semi-supervised approach for bootstrapping EHR phenotyping algorithms for primary care EHR in the UK Biobank, and b) to evaluate our approach by implementing and evaluating definitions on 31 commonly utilized clinical biomarkers.MethodsWe describe an algorithmic approach to defining phenotyping algorithms for extracting biomarker information from primary care EHR in the UKB. The main steps were: a) bootstrapping algorithm definitions using existing phenotype algorithms, b) excluding generic, rare or semantically-distant terms, c) forward-mapping Read version 2 terms to Clinical Terms Version 3, d) expert review and refinement, and e) data extraction and characterization. We evaluated the phenotyping algorithms by assessing the ability to reproduce known epidemiological associations by fitting Cox proportional hazards models with all-cause mortality as the endpoint.ResultsWe created and evaluated phenotyping algorithms from 31 biomarkers spanning biochemistry, haematological and physiological measurements directly related to known COVID-19 comorbidities and complications e.g. diabetes, cardiovascular
Whittaker H, Quint JK, 2020, Using routine health data for research: the devil is in the detail, Thorax, Vol: 75, Pages: 714-715, ISSN: 0040-6376
Rothnie KJ, Quint JK, 2020, Methodologic Issues With Comparative Effectiveness Study on LAMA-LABA-ICS vs LAMA-LABA for the Treatment of COPD in the Clinical Practice Research Datalink, CHEST, Vol: 158, Pages: 831-832, ISSN: 0012-3692
Gayle A, Quint JK, Fuertes E, 2020, Understanding the relationships between environmental factors and exacerbations of COPD, Expert Review of Respiratory Medicine, ISSN: 1747-6348
IntroductionExacerbations of chronic obstructive pulmonary disease (COPD) are associated with a significant health burden both for patients and healthcare systems. Exposure to various environmental factors increases the risk of exacerbations.Areas coveredWe searched PubMed and assessed literature published within the last 10 years to include epidemiological evidence on the relationships between air pollution, temperature and COPD exacerbation risk as well as the implications of extreme weather events on exacerbations.Expert opinionOngoing climate change is expected to increase air pollution levels, global temperature and the frequency and severity of extreme weather events, all of which are associated with COPD exacerbations. Further research is needed using patient-focused methodological approaches to better understand and quantify these relationships, so that effective mitigation strategies that decrease the risk of exacerbations can be developed.
Bloom C, de Preux L, sheikh A, et al., 2020, Health and cost impact of stepping down asthma medication for UK patients, 2001–2017: a population-based observational study, PLoS Medicine, Vol: 17, ISSN: 1549-1277
BackgroundGuidelines recommend stepping down asthma treatment to the minimum effective dose to achieve symptom control, prevent adverse side effects, and reduce costs. Limited data exist on asthma prescription patterns in a real-world setting. We aimed to evaluate the appropriateness of doses prescribed to a UK general asthma population and assess whether stepping down medication increased exacerbations or reliever use, as well as its impact on costs.Methods and findingsWe used nationwide UK primary care medical records, 2001–2017, to identify 508,459 adult asthma patients managed with preventer medication. Prescriptions of higher-level medication: medium/high-dose inhaled corticosteroids (ICSs) or ICSs + add-on medication (long-acting β2-agonist [LABA], leukotriene receptor antagonist [LTRA], theophylline, or long-acting muscarinic antagonist [LAMA]) steadily increased over time (2001 = 49.8%, 2017 = 68.3%). Of those prescribed their first preventer, one-third were prescribed a higher-level medication, of whom half had no reliever prescription or exacerbation in the year prior. Of patients first prescribed ICSs + 1 add-on, 70.4% remained on the same medication during a mean follow-up of 6.6 years. Of those prescribed medium/high-dose ICSs as their first preventer, 13.0% already had documented diabetes, cataracts, glaucoma, or osteopenia/osteoporosis. A cohort of 125,341 patients were drawn to assess the impact of stepping down medication: mean age 50.4 years, 39.4% males, 39,881 stepped down. Exposed patients were stepped down by dropping their LABAs or another add-on or by halving their ICS dose (halving their mean-daily dose or their inhaler dose). The primary and secondary outcomes were, respectively, exacerbations and an increase in reliever prescriptions. Multivariable regression was used to assess outcomes and determine the prognostic factors for initiating stepdown. There was no increased exacerbation risk for each possible medication stepdown (ad
Kiddle S, Whittaker H, Seaman S, et al., 2020, Prediction of five-year mortality after COPD diagnosis using primary care records, PLoS One, Vol: 15, ISSN: 1932-6203
Accurate prognosis information after a diagnosis of chronic obstructive pulmonary disease (COPD) would facilitate earlier and better informed decisions about the use of prevention strategies and advanced care plans. We therefore aimed to develop and validate an accurate prognosis model for incident COPD cases using only information present in general practitioner (GP) records at the point of diagnosis. Incident COPD patients between 2004–2012 over the age of 35 were studied using records from 396 general practices in England. We developed a model to predict all-cause five-year mortality at the point of COPD diagnosis, using 47,964 English patients. Our model uses age, gender, smoking status, body mass index, forced expiratory volume in 1-second (FEV1) % predicted and 16 co-morbidities (the same number as the Charlson Co-morbidity Index). The performance of our chosen model was validated in all countries of the UK (N = 48,304). Our model performed well, and performed consistently in validation data. The validation area under the curves in each country varied between 0.783–0.809 and the calibration slopes between 0.911–1.04. Our model performed better in this context than models based on the Charlson Co-morbidity Index or Cambridge Multimorbidity Score. We have developed and validated a model that outperforms general multimorbidity scores at predicting five-year mortality after COPD diagnosis. Our model includes only data routinely collected before COPD diagnosis, allowing it to be readily translated into clinical practice, and has been made available through an online risk calculator
Drake TM, Docherty AB, Harrison EM, et al., 2020, Outcome of hospitalisation for COVID-19 in patients with interstitial lung disease: an international multicentre study., Publisher: bioRxiv
Rationale: The impact of COVID-19 on patients with Interstitial Lung Disease (ILD) has not been established. Objectives: To assess outcomes following COVID-19 in patients with ILD versus those without in a contemporaneous age, sex and comorbidity matched population. Methods: An international multicentre audit of patients with a prior diagnosis of ILD admitted to hospital with COVID-19 between 1 March and 1 May 2020 was undertaken and compared with patients, without ILD obtained from the ISARIC 4C cohort, admitted with COVID-19 over the same period. The primary outcome was survival. Secondary analysis distinguished IPF from non-IPF ILD and used lung function to determine the greatest risks of death. Measurements and Main Results: Data from 349 patients with ILD across Europe were included, of whom 161 were admitted to hospital with laboratory or clinical evidence of COVID-19 and eligible for propensity-score matching. Overall mortality was 49% (79/161) in patients with ILD with COVID-19. After matching ILD patients with COVID-19 had higher mortality (HR 1.60, Confidence Intervals 1.17-2.18 p=0.003) compared with age, sex and co-morbidity matched controls without ILD. Patients with a Forced Vital Capacity (FVC) of <80% had an increased risk of death versus patients with FVC ≥80% (HR 1.72, 1.05-2.83). Furthermore, obese patients with ILD had an elevated risk of death (HR 1.98, 1.13−3.46). Conclusions: Patients with ILD are at increased risk of death from COVID-19, particularly those with poor lung function and obesity. Stringent precautions should be taken to avoid COVID-19 in patients with ILD.
Hurst JR, Quint JK, Stone RA, et al., 2020, National clinical audit for hospitalised exacerbations of COPD., ERJ Open Res, Vol: 6, ISSN: 2312-0541
Introduction: Exacerbations of COPD requiring hospital admission are burdensome to patients and health services. Audit enables benchmarking performance between units and against national standards, and supports quality improvement. We summarise 23 years of UK audit for hospitalised COPD exacerbations to better understand which features of audit design have had most impact. Method: Pilot audits were performed in 1997 and 2001, with national cross-sectional audits in 2003, 2008 and 2014. Continuous audit commenced in 2017. Overall, 96% of eligible units took part in cross-sectional audit, 86% in the most recent round of continuous audit. We synthesised data from eight rounds of national COPD audit. Results: Clinical outcomes were observed to change at the same time as changes in delivery of care: length of stay halved from 8 to 4 days between 1997 and 2014, alongside wider availability of integrated care. Process indicators did not generally improve with sequential cross-sectional audit. Under continuous audit with quality improvement support, process indicators linked to financial incentives (early specialist review (55-66%) and provision of a discharge bundle (53-74%)) improved more rapidly than those not linked (availability of spirometry (40-46%) and timely noninvasive ventilation (21-24%)). Conclusion: Careful piloting and engagement can result in successful roll-out of cross-sectional national audit in a high-burden disease. Audit outcome measures and process indicators may be affected by changes in care pathways. Sequential cross-sectional national audit alone was not generally accompanied by improvements in care. However, improvements in process indicators were seen when continuous audit was combined with quality improvement support and, in particular, financial incentives.
Hurst J, Quint J, Stone R, et al., National clinical audit for hospitalised exacerbations of chronic obstructive pulmonary disease, European Respiratory Journal, ISSN: 0903-1936
INTRODUCTION: Exacerbations of chronic obstructive pulmonary disease (COPD) requiring hospital admission are burdensome to patients and health services. Audit enables benchmarking performance between units, and against national standards, and supports quality improvement (QI). We summarise 22 years of UK audit for hospitalised COPD exacerbations to better understand which features of audit design have most impact.METHOD: Pilot audits were performed in 1997 and 2001, with national cross-sectional audits in 2003, 2008 and 2014. Continuous audit commenced in 2017. 96% of eligible units took part in cross-sectional audit, 86% in the most recent round of continuous. We synthesised data from eight rounds of national COPD audit.RESULTS: Clinical outcomes were observed to change at the same time as changes in delivery of care: length-of-stay halved from 8-4 days 1997-2014, alongside wider availability of integrated care. Process indicators did not generally improve with sequential cross-sectional audit. Under continuous audit with QI support, process indicators linked to financial incentives (early specialist review (55-66%) and provision of a discharge bundle (53-74%)) improved more rapidly than those without (availability of spirometry (40-46%) and timely non-invasive ventilation (21-24%)).CONCLUSION: Careful piloting and engagement of the target community can result in successful roll-out of cross-sectional national audit in a high-burden disease. Audit outcome measures and process indicators may be affected by changes in care pathways. Sequential cross-sectional national audit alone was not generally accompanied by improvements in care. However, ?improvements in process indicators were seen when continuous audit was combined with QI support and, in particular, financial incentives.
Bachtiger P, Adamson A, Quint JK, et al., 2020, Belief of Previous COVID-19 Infection and Unclear Government Policy are Associated with Reduced Willingness to Participate in App-Based Contact Tracing: A UK-Wide Observational Study of 13,000 Patients
<jats:p>Background:Contact tracing and lockdown are health policies being used worldwide to combat the coronavirus (COVID-19). While easing lockdown, the UK National Health Service (NHS) launched its Track and Trace Service at the end of May 2020, and aims by end of June 2020 also to include app-based notification and advice to self-isolate for those who have been in contact with a person known to have COVID-19. To be successful, such an app will require high uptake, the determinants and willingness for which are unclear but essential to understand for effective public health benefit.Objectives:To measure the determinants of willingness to participate in an NHS app-based contact tracing programme using a questionnaire within the Care Information Exchange (CIE) - the largest patient-facing electronic health record in the NHS.Methods:Observational study of 47,708 registered NHS users of the CIE, 27% of whom completed a novel questionnaire asking about willingness to participate in app-based contact tracing, understanding of government advice, mental and physical wellbeing and their healthcare utilisation -- related or not to COVID-19. Descriptive statistics are reported alongside univariate and multivariable logistic regression models, with positive or negative responses to a question on app-based contact tracing as the dependent variable. Results:26.1% of all CIE participants were included in the analysis (N = 12,434, 43.0% male, mean age 55.2). 60.3% of respondents were willing to participate in app-based contact tracing. Out of those who responded "no", 67.2% stated that this was due to privacy concerns. In univariate analysis, worsening mood, fear and anxiety in relation to changes in government rules around lockdown were associated with lower willingness to participate. Multivariable analysis showed that difficulty understanding government rules was associated with a decreased inclination to download the app, with those scoring 1-2 and 3-4 in t
Bloom C, Douglas I, Usmani OS, et al., 2020, Inhaled corticosteroid treatment regimens and health outcomes in a UK COPD population study [Corrigendum], The International Journal of Chronic Obstructive Pulmonary Disease, Vol: 15, Pages: 869-869, ISSN: 1176-9106
Sundaram V, Rothnie K, Bloom C, et al., 2020, Impact of comorbidities on peak troponin levels and mortality in acute myocardial infarction, Heart, Vol: 106, Pages: 677-685, ISSN: 1355-6037
OBJECTIVES: To characterise peak cardiac troponin levels, in patients presenting with acute myocardial infarction (AMI), according to their comorbid condition and determine the influence of peak cardiac troponin (cTn) levels on mortality. METHODS: We included patients with the first admission for AMI in the UK. We used linear regression to estimate the association between eight common comorbidities (diabetes mellitus, previous angina, peripheral arterial disease, previous myocardial infarction (MI), chronic kidney disease (CKD), cerebrovascular disease, chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD)) and peak cTn. Peak cTn levels were adjusted for age, sex, smoking status and comorbidities. Logistic regression and restricted cubic spline models were employed to investigate the association between peak cTn and 180-day mortality for each comorbidity. RESULTS: 330 367 patients with ST elevation myocardial infarction and non-ST elevation myocardial infarction were identified. Adjusted peak cTn levels were significantly higher in patients with CKD (adjusted % difference in peak cTnT for CKD=42%, 95% CI 13.1 to 78.4) and significantly lower for patients with COPD, previous angina, previous MI and CHF when compared with patients without the respective comorbidities (reference group) (cTnI; COPD=-21.7%, 95% CI -29.1 to -13.4; previous angina=-24.2%, 95% CI -29.6 to -8.3; previous MI=-13.5%, 95% CI -20.6 to -5.9; CHF=-28%, 95% CI -37.2 to -17.6). Risk of 180-day mortality in most of the comorbidities did not change substantially after adjusting for peak cTn. In general, cTnI had a stronger association with mortality than cTnT. CONCLUSIONS: In this nationwide analysis of patients presenting with AMI, comorbidities substantially influenced systemic concentrations of peak cTn. Comorbid illness is a significant predictor of mortality regardless of peak cTn levels and should be taken into consideration while interpr
Axson E, Sundaram V, Bloom C, et al., 2020, Temporal trends in the incidence of heart failure among patients with COPD and its association with mortality, Annals of the American Thoracic Society, Vol: 17, Pages: 939-948, ISSN: 1546-3222
Rationale: Heart failure (HF) is a common comorbidity in the chronic obstructive pulmonary disease (COPD) population, but previous research has shown under recognition. Objectives: To determine the incidence of HF in a prevalent COPD cohort. To determine the association of incident HF with short- and long-term mortality of patients with COPD. Methods: Crude incidence of HF in the HF-naïve primary care COPD population was calculated for each year from 2006-2016 using UK data from the Clinical Practice Research Datalink (CPRD). Patients with COPD were identified using a validated code list and were required to be over 35 years old at COPD diagnosis, have a history of smoking, and have documented airflow obstruction. Office of National Statistics provided mortality data for England. Adjusted mortality rate ratios (aMRR) from Poisson regression were calculated for patients with COPD and incident HF (COPD-iHF) in 2006, 2011, and 2015 and compared temporally with patients with COPD and without incident HF (COPD-no HF) in those years. Regression was adjusted for age, sex, BMI, severity of airflow limitation, smoking status, history of cardiovascular disease, and diabetes. Results: We identified 95,987 HF-naïve patients with COPD. Crude incidence of HF was steady from 2006-2016 (1.18 per 100 person-years (95%CI: 1.09, 1.27)). Patients with COPD-iHF experienced greater than threefold increase in one-year mortality and twofold increase in five-year and 10-year mortality compared with patients with COPD-no HF, with no change based on year of HF diagnosis. Mortality of patients with COPD-iHF did not improve over time, comparing incident HF in 2011 (1-year aMRR 1.26, 95%CI: 0.83, 1.90; 5-year aMRR 1.26, 95%CI: 0.98, 1.61) and 2015 (1-year aMRR 1.63, 95%CI: 0.98, 2.70) with incident HF in 2006. Conclusions: The incidence of HF in the UK COPD population was stable in the last decade. Survival of patients with COPD and incident HF has not improved over time in England. Be
Bloom CI, Douglas I, Usmani OS, et al., 2020, Inhaled corticosteroid treatment regimens and health outcomes in a UK COPD population study, The International Journal of Chronic Obstructive Pulmonary Disease, Vol: 15, Pages: 701-710, ISSN: 1176-9106
Background: Inhaled corticosteroids (ICS) are a prevailing treatment option for COPD patients but recent guidelines have relegated their use predominantly to patients with frequent exacerbations. Yet large numbers of patients worldwide are currently treated with ICS-containing regimens. We wished to determine in routine clinical practice how common ICS withdrawal is and the differences in health outcomes between patients managed on ICS-containing and non-ICS containing regimens.Patients and Methods: COPD patients were identified from the UK primary care electronic healthcare records, between 2014 and 2018. Patients were grouped into three treatment regimens: long-acting beta-agonist (LABA) and inhaled corticosteroids (ICS), LABA and long-acting muscarinic antagonist (LAMA), and triple therapy (LABA, LAMA and ICS). Annual incidence of ICS withdrawal was measured. Multivariable logistic regression was used to identify patient factors associated with withdrawal. Multivariable Poisson regression was used to assess the association of exacerbations and hospitalised pneumonia between the ICS-containing regimens (LABA-ICS and triple therapy) and patients prescribed LABA-LAMA.Results: Of 117,046 patients, around three-quarters were prescribed ICS-containing inhalers but ICS withdrawal occurred annually in only approximately 2– 3% of patients. Exacerbations in the past year, but not a past history of pneumonia, were associated with ICS withdrawal. A total of 31,034 patients using three treatment regimens (LABA-ICS, LABA-LAMA or triple therapy) were assessed for their relative risk of exacerbations and pneumonia; the exacerbation risk was slightly lower in LABA-ICS users but the same in triple therapy users, as compared to LABA-LAMA users (LABA-ICS adjusted IRR=0.82 (95% CI 0.73– 0.93), triple adjusted IRR=0.99 (95% CI 0.88– 1.11)). There was no difference in the pneumonia risk (LABA-ICS adjusted IRR=0.96 (95% CI 0.71– 1.31), triple adjusted IRR=1.16 (
Tran T, King E, Sarkar R, et al., 2020, Oral corticosteroid prescription patterns for asthma in France, Germany, Italy, and the United Kingdom, European Respiratory Journal, Vol: 55, ISSN: 0903-1936
Oral corticosteroids (OCS) are used to manage asthma exacerbations and severe, uncontrolled asthma, but OCS use is associated with adverse effects. We aimed to describe the patterns of OCS use in the real-world management of patients with asthma in western Europe.We used electronic medical records from databases in France, Germany, Italy, and the United Kingdom from July 2011 through February 2018. Patients aged ≥12 years with an asthma diagnosis, ≥1 non-OCS asthma medication within ±6 months of diagnosis, and available data ≥6 months prior to and ≥90 days after cohort entry were included. High OCS use was defined as OCS ≥450 mg prescribed in a 90-day window during follow-up. Baseline characteristics and OCS use during follow-up were described overall and by OCS use status.Of 702 685 patients with asthma, 14–44% were OCS users and 6–9% were high OCS users at some point during follow-up. Annual prevalence of high OCS use across all countries was approximately 3%. High OCS users had a mean 1–3 annual OCS prescriptions, with an average daily OCS dosage of 1.3–2.2 mg. For patients who continued to meet the high use definition, daily OCS exposure was generally stable at 5.5–7.5 mg for at least 2 years, increasing the risk of adverse effects.Our study demonstrates that OCS use is relatively common across the four studied European countries. Data from this study may provide decisive clinical insights to inform primary care physicians and specialists involved in the management of severe, uncontrolled asthma.
Janson C, Menzies-Gow A, Nan C, et al., 2020, SABINA: an overview of short-acting β2-agonist use in asthma in European countries, Advances in Therapy, Vol: 37, Pages: 1124-1135, ISSN: 0741-238X
IntroductionGlobally, individuals with asthma tend to overrely on short-acting β2-agonists (SABAs) and underuse inhaled corticosteroids, thereby undertreating the underlying inflammation. Such relief-seeking behavior has been reinforced by long-standing treatment guidelines, which until recently recommended SABA-only use for immediate symptom relief. We aimed to describe the current burden of SABA use among European individuals with asthma within the SABA use IN Asthma (SABINA) program.MethodsPrescription and/or dispensing data during 2006–2017 from electronic medical records and/or national patient registries in the United Kingdom (UK), Germany, Italy, Spain, and Sweden were analyzed. Individuals aged at least 12 years old with a current asthma diagnosis and no other chronic respiratory conditions were included. Asthma treatment step and severity were based on treatment guidelines in use in each individual country. The proportion of individuals prescribed SABA was measured during a 12-month period. SABA overuse was defined as at least three SABA canisters per year.ResultsMore than one million individuals with asthma were included across five European countries. Overall, the majority of individuals were over 45 years of age, except in Sweden (mean age 27.6 years) where individuals aged over 45 years were excluded to avoid a potential chronic obstructive pulmonary disease co-diagnosis. The study population was predominantly female (55–64%), except in the UK (46%). The prevalence of SABA overuse was 9% in Italy, 16% in Germany, 29% in Spain, 30% in Sweden, and 38% in the UK. In the UK, SABA overuse was greater in individuals with moderate-to-severe asthma versus individuals with mild asthma (58% versus 27%, respectively), while SABA overuse was similar in individuals with both mild (9–32%) and moderate-to-severe (8–31%) asthma in the other European countries.ConclusionsThe findings of this study from the SABINA program show that SABA overu
Stone P, Sood N, Feary J, et al., 2020, Validation of acute exacerbation of chronic obstructive pulmonary disease (COPD) recording in electronic health records: a systematic review protocol, BMJ Open, Vol: 10, ISSN: 2044-6055
Introduction Many patients with chronic obstructive pulmonary disease (COPD) experience a sustained worsening in symptoms termed an acute exacerbation (AECOPD). AECOPDs impact on patients’ quality of life and lung function, are costly to health services and are an important topic for research. Electronic health records (EHR) are increasingly being used to study AECOPD, requiring accurate detection of AECOPD in EHRs to ensure generalisable results. The aim of this protocol is to provide an overview of studies that validate AECOPD definitions used in EHRs and administrative claims databases.Methods and analysis Medline and Embase will be searched for terms related to COPD exacerbation, EHRs and validation. All studies published between 1 January 1990 and 30 September 2019 written in English that validate AECOPD in EHRs and administrative claims databases will be considered. Inclusion criteria: EHR data must be routinely collected; the AECOPD detection algorithm must be compared against a reference standard; and a measure of validity must be calculable. Two independent reviewers will screen articles for inclusion, extract study details and assess risk of bias using QUADAS-2. Disagreements will be resolved by consensus or arbitration by a third reviewer. This protocol has been developed in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols checklist.Ethics and dissemination This will be a review of previously published literature therefore no ethical approval is required. Results from this review will be published in a peer-reviewed journal. The results can be used in future research to identify occurrences of AECOPD.
Axson E, Ragutheeswaran K, Sundaram V, et al., 2020, Hospitalisation and mortality in patients with comorbid COPD and heart failure: a systematic review and meta-analysis, Respiratory Research, Vol: 21, Pages: 1-13, ISSN: 1465-9921
BackgroundDiscrepancy exists amongst studies investigating the effect of comorbid heart failure (HF) on the morbidity and mortality of chronic obstructive pulmonary disease (COPD) patients.MethodsMEDLINE and Embase were searched using a pre-specified search strategy for studies comparing hospitalisation, rehospitalisation, and mortality of COPD patients with and without HF. Studies must have reported crude and/or adjusted rate ratios, risk ratios, odds ratios (OR), or hazard ratios (HR).ResultsTwenty-eight publications, reporting 55 effect estimates, were identified that compared COPD patients with HF with those without HF. One study reported on all-cause hospitalisation (1 rate ratio). Two studies reported on COPD-related hospitalisation (1 rate ratio, 2 OR). One study reported on COPD- or cardiovascular-related hospitalisation (4 HR). One study reported on 90-day all-cause rehospitalisation (1 risk ratio). One study reported on 3-year all-cause rehospitalisation (2 HR). Four studies reported on 30-day COPD-related rehospitalisation (1 risk ratio; 5 OR). Two studies reported on 1-year COPD-related rehospitalisation (1 risk ratio; 1 HR). One study reported on 3-year COPD-related rehospitalisation (2 HR). Eighteen studies reported on all-cause mortality (1 risk ratio; 4 OR; 24 HR). Five studies reported on all-cause inpatient mortality (1 risk ratio; 4 OR). Meta-analyses of hospitalisation and rehospitalisation were not possible due to insufficient data for all individual effect measures. Meta-analysis of studies requiring spirometry for the diagnosis of COPD found that risk of all-cause mortality was 1.61 (pooled HR; 95%CI: 1.38, 1.83) higher in patients with HF than in those without HF.ConclusionsIn this systematic review, we investigated the effect of HF comorbidity on hospitalisation and mortality of COPD patients. There is substantial evidence that HF comorbidity increases COPD-related rehospitalisation and all-cause mortality of COPD patients. The effect of HF
Whittaker H, Connell O, Campbell J, et al., 2020, Eligibility for lung volume reduction surgery in chronic obstructive pulmonary disease patients identified in a UK primary care setting, Chest, Vol: 157, Pages: 276-285, ISSN: 0012-3692
BackgroundAlthough lung volume reduction surgery (LVRS) improves survival in appropriately selected patients with Chronic Obstructive Pulmonary Disease (COPD), few procedures are performed. The National Institute for Clinical and Healthcare Excellence recently recommended a more systematic approach to identifying potential candidates. We investigated LVRS referrals from a UK primary care population and aimed to establish an accurate estimate of eligible patients and determine a strategy for identifying potential candidates systematically.MethodsClinical Practice Research Datalink (CPRD) GOLD (a primary care database), linked Hospital Episode Statistics (HES) inpatient and Diagnostic Imaging Dataset (DID) were used. COPD patients who had undergone LVRS, patients who met basic eligibility criteria for further screening for LVRS, and patients meeting a more stringent eligibility criteria were identified from April 2012 to September 2015. Thoracic CT, pulmonary rehabilitation status, referral to respiratory outpatient clinics, and AECOPD requiring hospitalisation were compared between actual LVRS recipients and potentially eligible patients. ResultsAmong 73,697 COPD patients included, 36 (0.05%) received LVRS, 5,984 (8.1%) met basic eligibility criteria, and 159 (0.2%) met more stringent eligibility criteria. LVRS recipients were younger (mean(SD) age: 64(9.2) years) compared to the stringently eligible patients (69(8.9) years) (p=0.01). Few patients meeting stringent eligibility criteria (6.9%) had a CT thorax in the preceding 3 years or been referred for assessment in secondary care. ConclusionsA substantial unmet need exists among COPD patients who could potentially benefit from a lung volume reduction procedure but who are not being investigated or referred to consider this possibility.
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