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Editorials |

COPDCOPD and Hospitalization: Undefeated! FREE TO VIEW

Mohsen Sadatsafavi, MD, PhD; Don D. Sin, MD, FCCP
Author and Funding Information

From the Division of Respiratory Medicine (Drs Sadatsafavi and Sin), University of British Columbia; and the Center for Clinical Epidemiology and Evaluation (Dr Sadatsafavi), and the James Hogg Research Centre (Dr Sin), St. Paul’s Hospital.

CORRESPONDENCE TO: Don D. Sin, MD, FCCP, Room 8446, St. Paul’s Hospital, Vancouver, BC, V6Z 1Y6, Canada; e-mail: don.sin@hli.ubc.ca


FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST the following conflicts: Dr Sin has received honoraria for speaking engagements from drug companies including AstraZeneca, Merck & Co, Boehringer Ingelheim GmbH, Takeda Pharmaceutical Company Limited, and Grifols; has received investigator-initiated grants from AstraZeneca, Boehringer Ingelheim GmbH, and Grifols; and has sat on scientific advisory boards of Almirall and AstraZeneca. Dr Sadatsafavi reports no potential conflicts of interest with any companies/organizations whose productions 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. 2015;147(4):868-869. doi:10.1378/chest.14-2979
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Published online

In 1968, the Phillip Morris Company launched a memorable campaign to sell its cigarettes, Virginia Slims, using a catchy slogan: “You’ve come a long way, baby,” which led to a massive increase in sales of cigarettes, especially among women, and launched the modern epidemic of COPD in the United States. Today, there are > 12.7 million Americans with COPD, and nearly 140,000 Americans succumb to this disease every year.1 Over the past 2 decades, there has been a concerted effort to find new therapeutic solutions to address the growing burden of COPD. How have we done?

The study by Ford,2 published in this issue of CHEST (see page 989), reports on the COPD hospitalization rates over the previous 10 years in the United States. The results are largely disappointing and provide a sobering reminder that the epidemic of COPD is far from defeated.2 Using large and representative datasets of the US population, Ford determined the trends in hospitalization for COPD from 2001 to 2012 and emergency visits from 2006 to 2012. He found that these rates have increased by 20% to 30% during this time, and between 2002 and 2012, the inpatient charges for COPD have increased by an astonishing 125%. Readmissions were also stubbornly high at 21%, with most patients coming back to the hospital because of their poorly controlled COPD.

The most discouraging news comes from the author’s clever juxtaposition of COPD numbers with similar figures for common cardiovascular disorders. The rates of hospitalization for these conditions have decreased significantly, with the most dramatic improvements observed in hospitalizations related to coronary artery disease and congestive heart failure, for which the age-adjusted rates have dropped by 70% and 40%, respectively, between 2001 and 2012. These striking reductions in cardiovascular hospitalizations likely reflect major improvements in therapeutics as well as primary and secondary preventions of disease and provide hope that with improved care and treatment of patients with COPD in the future, these hospitalization rates can also decrease.

An inevitable concern with such types of data is to what extent the observed trends might have been affected by the evolution of sampling methods. During the study period, the number of participating states providing hospitalization data increased by 39%, and the entire survey experienced a major redesign in 2012. Another concern lies with the changes in diagnostic classification of COPD that might have occurred over the study period. Even subtle changes in physicians’ propensity for labeling a certain clinical event as COPD hospitalization vs another condition can easily affect population trends, a phenomenon commonly referred to as diagnostic exchange (or diagnostic drift).3 This is especially relevant for COPD, in which misdiagnosis can occur owing to its nonspecific symptoms and association with multiple comorbid conditions that might mask or intensify respiratory symptoms. However, given the large and robust sample sizes and comprehensiveness of data collection, it is unlikely that these secular trends can easily explain away the findings of the study.

The study by Ford2 is an efficient use of publicly available data that generate a wealth of important information. In addition to raising awareness of COPD in the community, such information is critical for several stakeholder groups. It enables investigators to estimate the return on investment from their research and knowledge translation, policy makers to prioritize the allocation of increasingly scarce health-care dollars or research funds, and clinical experts to formulate best practice guidelines that can have a high impact on public health.

How can we build on this and other related studies? First, such analyses need to be repeated in different jurisdictions to provide a more complete picture of the global burden of COPD. Different patterns might surface in countries with different health-care systems or different populations or environmental trends, and investigating such differences may shed light on potential factors driving the high rates of hospitalization in the United States. Second, the methodology of these studies can be improved. We suggest the use of controlled (eg, matched) designs that allow investigators to subtract the background (secular) trends in the general population. The research community should also couple such descriptive, hypothesis-generating analyses with analytic, hypothesis-driven ones. The trends observed in this study are the result of the complex interplay of several dynamic risk factors, including an aging population, declining smoking rates, arrival of new treatments, changes in outpatient care, diagnostic exchanges, and reduction in the burden of competing diseases. It will be tremendously informative to tease out the population-attributable fraction of these and other factors regarding the burden of COPD. This will require access to larger and more unified data as well as use of more advanced statistical techniques that can establish causal relations. Computational methods such as disease simulations can build upon these findings and enable the prediction of the future burden of COPD under various policies. Such groundbreaking and action-oriented research has been carried out in other chronic diseases.4

Notwithstanding these limitations, the data by Ford2 are a strong reminder that the war against COPD is far from complete. Although tobacco reduction is critical in this fight, it is by no means sufficient. There is a pressing need to develop novel therapeutics and management strategies to improve COPD care and outcomes. However, this can only be achieved when there is sufficient investment in research and development. Regrettably, COPD is the most underfunded disease in the United States relative to its burden,5 and unless this changes, hospitalizations and repeat hospitalizations will be the norm for the patients with COPD. The data by Ford are a clear reminder that the battle against COPD still has a long way to go!

References

American Lung Association. Chronic Obstructive Pulmonary Disease (COPD) fact sheet. http://www.lung.org/lung-disease/copd/resources/facts-figures/COPD-Fact-Sheet.html. Accessed November 24, 2014.
 
Ford ES. Hospital discharges, readmissions, and ED visits for COPD or bronchiectasis among US adults: findings from the Nationwide Inpatient Sample 2001-2012 and Nationwide Emergency Department Sample 2006-2011. Chest. 2015;147(4):989-998.
 
Fransoo RR, Martens PJ, Prior HJ, et al; Need to Know Team. The rising prevalence of asthma: true increase, diagnostic exchange or diagnostic accuracy? Healthc Policy. 2013;8(4):27-34. [PubMed]
 
Bibbins-Domingo K, Chertow GM, Coxson PG, et al. Projected effect of dietary salt reductions on future cardiovascular disease. N Engl J Med. 2010;362(7):590-599. [CrossRef] [PubMed]
 
Gillum LA, Gouveia C, Dorsey ER, et al. NIH disease funding levels and burden of disease. PLoS ONE. 2011;6(2):e16837. [CrossRef] [PubMed]
 

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References

American Lung Association. Chronic Obstructive Pulmonary Disease (COPD) fact sheet. http://www.lung.org/lung-disease/copd/resources/facts-figures/COPD-Fact-Sheet.html. Accessed November 24, 2014.
 
Ford ES. Hospital discharges, readmissions, and ED visits for COPD or bronchiectasis among US adults: findings from the Nationwide Inpatient Sample 2001-2012 and Nationwide Emergency Department Sample 2006-2011. Chest. 2015;147(4):989-998.
 
Fransoo RR, Martens PJ, Prior HJ, et al; Need to Know Team. The rising prevalence of asthma: true increase, diagnostic exchange or diagnostic accuracy? Healthc Policy. 2013;8(4):27-34. [PubMed]
 
Bibbins-Domingo K, Chertow GM, Coxson PG, et al. Projected effect of dietary salt reductions on future cardiovascular disease. N Engl J Med. 2010;362(7):590-599. [CrossRef] [PubMed]
 
Gillum LA, Gouveia C, Dorsey ER, et al. NIH disease funding levels and burden of disease. PLoS ONE. 2011;6(2):e16837. [CrossRef] [PubMed]
 
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