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Pedro Almagro, MD; Joan B. Soriano, MD
Author and Funding Information

From the Internal Medicine Service (Dr Almagro), Hospital Universitario Mutua De Terrassa, Universidad de Barcelona; and FISIB-IdISPA Hospital Universitari Son Espases (Dr Soriano).

Correspondence to: Pedro Almagro, MD, Internal Medicine Service, Hospital Universitario Mutua De Terrassa, Universidad de Barcelona, Plaza Dr Robert No. 5, 08221, Terrassa, Barcelona, Spain; e-mail: 19908pam@comb.cat


Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Almagro participated in speaking activities, industry advisory committees, and other related activities sponsored by Takeda Nycomed; Almirall, SA; Boehringer-Ingelheim GmbH; Pfizer Inc; Chiesi Pharmaceuticals; GlaxoSmithKline; The Menarini Group; Merck, Sharp & Dohme; and Novartis. Dr Soriano has reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;145(5):1172-1173. doi:10.1378/chest.13-2576
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Published online
To the Editor:

We appreciate the comments of Dr Hadda and colleagues about our article.1 We agree with their first statement that the Charlson index does not include all relevant comorbidities in patients with COPD. However, the Charlson index is an excellent predictor of mortality after hospitalization in these patients.2 Actually, as highlighted in the Materials and Methods section of our article, the development cohort of the CODEX (comorbidity, obstruction, dyspnea, and previous severe exacerbations) index is based on previously published research (the ESMI [EPOC en Servicios de Medicina Interna] study) conducted specifically to assess up to 30 different comorbidities in patients hospitalized for an acute exacerbation of COPD, regardless of whether included in the Charlson index. In that study, several comorbidities were associated with a greater mortality at 3 months after discharge, most of them included in the Charlson index. Of note, the Charlson index was an independent predictor of mortality, even after adjustment for age, FEV1, and physical functional status (Katz scale).3 With respect to the second observation by Dr Hadda and colleagues, comorbidity data were collected from a specific questionnaire that included all pathologies considered relevant in patients with COPD. Comorbidity data were collected by physicians through both medical history and explorations indicated for diagnosis according to usual clinical practice.

Finally, Dr Hadda and colleagues refer to the Charlson index score reflected in Table 2 of our article, which is an average of 3 and 2 points in the development and validation cohorts, respectively. Obviously, it is not possible to have a mean Charlson score adjusted by age of ≤ 3 points in patients with COPD aged > 70 years because the minimum score in this situation is 4. The explanation is that in Table 2, comorbidity is expressed through the most frequently used version of Charlson index, that is, without age adjustment, because the mean age of the patients in each cohort is included in the same table, and adding the Charlson index score adjusted for age seemed redundant. Conversely, when we referred to the index adjusted by age (less used), it is expressly specified (Table 1, e-Table 1 in our article). In this situation, a mean score of 3 points implies the concurrence of COPD and two other chronic diseases or other more severe disease. Of interest, the increase of comorbidity observed in patients hospitalized for COPD between the ESMI study (most recent) and another previous cohort has been described, highlighting its growing importance in this population.4,5

References

Almagro P, Soriano J, Cabrera F, et al; Working Group on COPD, Spanish Society of Internal Medicine. Short- and medium-term prognosis in patients hospitalized for COPD exacerbation: the CODEX index. Chest. 2014;145(5):972-980.
 
Almagro P, Calbo E, Ochoa de Echagüen A, et al. Mortality after hospitalization for COPD. Chest. 2002;121(5):1441-1448. [CrossRef] [PubMed]
 
Almagro P, Cabrera FJ, Diez J, et al; Working Group on COPD, Spanish Society of Internal Medicine. Comorbidities and short-term prognosis in patients hospitalized for acute exacerbation of COPD: The EPOC en Servicios de medicina interna (ESMI) study. Chest. 2012;142(5):1126-1133. [CrossRef] [PubMed]
 
Almagro P, López F, Cabrera FJ, et al; Grupos de trabajo de EPOC y Paciente Pluripatológico y Edad Avanzada de la Sociedad Española de Medicina Interna. Comorbidities in patients hospitalized due to chronic obstructive pulmonary disease. A comparative analysis of the ECCO and ESMI studies [in Spanish]. Rev Clin Esp. 2012;212(6):281-286. [CrossRef] [PubMed]
 
Decramer M, Janssens W. Chronic obstructive pulmonary disease and comorbidities. Lancet Respir Med. 2013;1(1):73-83. [CrossRef] [PubMed]
 

Figures

Tables

References

Almagro P, Soriano J, Cabrera F, et al; Working Group on COPD, Spanish Society of Internal Medicine. Short- and medium-term prognosis in patients hospitalized for COPD exacerbation: the CODEX index. Chest. 2014;145(5):972-980.
 
Almagro P, Calbo E, Ochoa de Echagüen A, et al. Mortality after hospitalization for COPD. Chest. 2002;121(5):1441-1448. [CrossRef] [PubMed]
 
Almagro P, Cabrera FJ, Diez J, et al; Working Group on COPD, Spanish Society of Internal Medicine. Comorbidities and short-term prognosis in patients hospitalized for acute exacerbation of COPD: The EPOC en Servicios de medicina interna (ESMI) study. Chest. 2012;142(5):1126-1133. [CrossRef] [PubMed]
 
Almagro P, López F, Cabrera FJ, et al; Grupos de trabajo de EPOC y Paciente Pluripatológico y Edad Avanzada de la Sociedad Española de Medicina Interna. Comorbidities in patients hospitalized due to chronic obstructive pulmonary disease. A comparative analysis of the ECCO and ESMI studies [in Spanish]. Rev Clin Esp. 2012;212(6):281-286. [CrossRef] [PubMed]
 
Decramer M, Janssens W. Chronic obstructive pulmonary disease and comorbidities. Lancet Respir Med. 2013;1(1):73-83. [CrossRef] [PubMed]
 
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