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Adherence to current guidelines for chronic obstructive pulmonary disease (COPD) among patients treated with combination of long-acting bronchodilators or inhaled corticosteroids.

To estimate the potential cost savings by following the current Global Initiative for Chronic Obstructive Lung Disease (GOLD) guideline recommendations in patients being treated for chronic obstructive pulmonary disease (COPD) with the combination of long-acting β(2)-agonist (LABA), long-acting muscarinic antagonist (LAMA) or inhaled corticosteroids (ICS).

METHODS: The Geisinger Health System (GHS) database was utilized to identify subjects between January 1, 2004 to March 12, 2007. The index date was based on the first prescription of a LAMA plus LABA, LAMA plus LABA/ICS, or LABA plus ICS. Patients were included in the study if they: had a COPD diagnosis; had data representative of treatment 12 months prior to and 12 months post index date; were 40 years of age or over; had no prior diagnosis for asthma; and had pulmonary function test (PFT) data. We examined the baseline characteristics of these patients along with their healthcare resource utilization. Based on PFT data within 30 days of the index date, a subgroup was classified as adhering or non-adhering to GOLD guidelines.

RESULTS: A total of 364 subjects could be classified as adhering or non-adherent to current GOLD guidelines based on their PFT results. The adherent subgroup received COPD medications consistent with current GOLD guidelines. Of the LAMA plus LABA cohort, 25 patients adhered and 39 patients were non-adherent to current GOLD guidelines. In the cohort of LABA plus ICS, 74 patients were adherent and 180 patients non-adherent to current GOLD guidelines. In the cohort of LAMA plus LABA/ICS, 21 patients were adherent and 25 patients non-adherent to current GOLD guidelines. GOLD adherence was associated with mean total cost of all services savings of $5,889 for LAMA plus LABA, $3,330 for LABA + ICS, and $10,217 for LAMA plus LABA/ICS cohorts.

CONCLUSION: Staging of COPD with a PFT and adherence to current GOLD guidelines was associated with lower costs in subjects with moderate to severe COPD. Appropriate use of LAMA plus LABA, LABA plus ICS, and LAMA plus LABA/ICS has economic as well as clinical benefits for patients and payers.

The burden of chronic obstructive pulmonary disease among employed adults.

OBJECTIVE: To examine quality of life, work productivity, and health care resource use among employed adults ages 40-64 years with chronic obstructive pulmonary disease (COPD) in the United States.

METHODS: Data from the 2009 National Health and Wellness Survey were used. All employed adults ages 40-64 years with or without a self-reported diagnosis of COPD were included in the study. Impact on quality of life (using the mental and physical component summary scores and health utilities from the Short Form-12v2), work productivity and activity impairment (using the Work Productivity and Activity Impairment questionnaire), and resource use were analyzed using regression modeling.

RESULTS: There were 1112 employed adults with COPD versus 18,912 employed adults without COPD. After adjusting for demographics and patient characteristics, adults with COPD reported significantly lower mean levels of mental component summary (46.8 vs 48.5), physical component summary (45.6 vs 49.2), and health utilities (0.71 vs 0.75) than adults without COPD. Workers with COPD reported significantly greater presenteeism (18.9% vs 14.3%), overall work impairment (20.5% vs 16.3%), and impairment in daily activities (23.5% vs 17.9%) than adults without COPD. Employed adults with COPD also reported more mean emergency room visits (0.21 vs 0.12) and more mean hospitalizations (0.10 vs 0.06) in the previous 6 months than employed adults without COPD. All of the above differences were significant at two-sided P < 0.05.

CONCLUSION: After adjusting for various confounders, employed adults with COPD reported significantly lower quality of life and work productivity, and increased health care resource utilization than employed adults without COPD. These results highlight the substantial impact and burden of COPD in the United States workforce.

Mechanisms of pulmonary hypertension in chronic obstructive pulmonary disease: A pathophysiologic review.

Chronic obstructive pulmonary disease (COPD) is a major cause of mortality and morbidity worldwide and is often complicated by the development of pulmonary hypertension (PHT).

The presence of PHT in COPD subjects is associated with increased mortality, morbidity and use of health-care resources. Thus, there has been significant effort to treat PHT in COPD patients to achieve improved clinical outcomes, but with only minimal success. There is renewed interest in understanding the mechanisms contributing to PHT in COPD as the basis for exploring new therapeutic strategies.

In this study we review the evidence supporting the postulated mechanisms contributing to PHT in COPD. Hypoxia plays a pivotal role in the development of COPD-associated PHT. However, other mechanisms are also likely involved in the pathogenesis of increased pulmonary vascular resistance in this cohort, including acidemia, dynamic pulmonary hyperinflation, parenchymal destruction, pulmonary vascular remodeling, endothelial dysfunction and inflammation. These mechanisms are interdependent, modulated by genetic factors, and may be confounded by comorbidities such as sleep-disordered breathing, left heart failure and pulmonary thromboembolism.

Despite significant research in recent decades, there is surprisingly little evidence of a causal relationship between many of these factors and the development of COPD-associated PHT. The pathogenesis of PHT in COPD is complex and multifaceted. Ultimately, as we obtain better information on COPD phenotypes, we may be able to more precisely account for the varied pathologic mechanisms of PHT occurring in various COPD patients.

This may ultimately enable targeted PHT therapy for each COPD phenotype.

Effect of Exercise Training in Patients With Chronic Obstructive Pulmonary Disease Compared With Healthy Elderly Subjects.

Exercise training in patients with chronic obstructive pulmonary disease (COPD) can be challenging because whole-body exercise often elicits disabling symptoms of dyspnea before the exercising muscles reach their critical limits. The extent that this factor limits training has not been totally defined.

The purpose of this study was to compare the response to training of patients with moderate to severe COPD with that achieved by healthy elderly subjects who were exercising using an identical program.

METHODS:: Eight healthy subjects and 20 patients with COPD (forced expiratory volume in 1 second 42 ± 13% predicted) exercised 3 times a week for 8 weeks. Outcome measures included 6-minute walk distance, maximal exercise capacity (Wmax) during an incremental cycle ergometer test, and submaximal constant workload (60%-70% of subject Wmax) exercise time.

RESULTS:: Six-minute walk distance and Wmax increased after training to a significantly greater extent in the healthy controls compared with the patients with COPD; 65 ± 24 versus 32 ± 50 m, P = .03; and 25.1±13.9 versus 11.5±13.1 watts, P = .025, respectively. However, these differences disappeared when data were expressed as percent improvement, 12.1 ± 5.3% versus 10.0 ± 15.8%, and 25.6 ± 13.5% versus 23.1 ± 33.3%. Improvement in submaximal constant workload exercise time after training was similar in healthy controls 21.6 ± 6.1 versus patients with COPD 18.8 ± 11.2 minutes.

CONCLUSIONS:: Patients with COPD can show similar relative improvements in exercise capacity compared with healthy elderly subjects. The difference in absolute values reflects, at least in part, the greater baseline exercise capacity.

Spirometric Thresholds for Diagnosing COPD: 0.70 or LLN, Pre- or Post-dilator Values?

In absence of a gold standard for chronic obstructive pulmonary disease (COPD) it remains difficult to compare the true diagnostic characteristics of the forced expiratory volume in 1 second to the forced vital capacity (FEV(1)/FVC) <0.70 and < lower limit of normal (LLN).

COPD is a clinical diagnosis, based on symptoms signs and lung function results combined, and an expert panel assessment would be an adequate reference standard.

We compared the diagnostic properties of FEV(1)/FVC <LLN and <0.70 against this panel diagnosis: 342 participants, aged >50, consulting for persistent cough, but without physician-diagnosed COPD, were prospectively enrolled. All underwent extensive history taking, physical examination, spirometry and diffusion testing. An expert panel, including a board certified respiratory physician, assessed all diagnostic information to determine the presence or absence of COPD and served as reference standard. Then, 104 participants were diagnosed with COPD by the panel.

The reproducibility of the panel diagnosis was high (kappa of 0.94). Sensitivity estimates of <0.70 were significantly higher than that of <LLN (0.73 and 0.47, respectively, p < 0.001). The fixed approach was less specific than the LLN (0.95 and 0.99, respectively, p < 0.001).

There was no significant difference in diagnostic property when using pre- or post-bronchodilator FEV(1)/FVC (p = 0.615). In a symptomatic primary care population, the FEV(1)/FVC <0.70 was more accurate to detect COPD.

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