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COPD Comorbidity Profiles and 2-Year Trajectory of Acute and Postacute Care Use

Published:January 18, 2021DOI:https://doi.org/10.1016/j.chest.2021.01.020

      Background

      Multiple morbidity is the norm in advanced COPD and contributes to high symptom burden and worse outcomes.

      Research Question

      Can distinct comorbidity profiles be identified and validated in a community-based sample of patients with COPD from a large integrated health care system using a standard, commonly used diagnostic code-based comorbidity index and downstream 2-year health care use data?

      Study Design and Methods

      In this retrospective cohort study, we used latent class analysis (LCA) to identify comorbidity profiles in a population-based sample of 91,453 patients with a COPD diagnosis between 2011 and 2015. We included specific comorbid conditions from the Charlson Comorbidity Index (CCI) and accounted for variation in underlying prevalence of different comorbidities across the three study sites. Sociodemographic, clinical, and health-care use data were obtained from electronic health records (EHRs). Multivariate logistic regression analysis was used to compare rates of acute and postacute care use by class.

      Results

      The mean age was 71 ± 11 years, 55% of patients were women, 23% of patients were people of color, and 80% of patients were former or current smokers. LCA identified four distinct comorbidity profiles with progressively higher CCI scores: low morbidity (61%; 1.9 ± 1.4), metabolic renal (21%; 4.7 ± 1.8), cardiovascular (12%; 4.6 ± 1.9), and multimorbidity (7%; 7.5 ± 1.7). In multivariate models, during 2 years of follow-up, a significant, nonoverlapping increase was found in the odds of having any all-cause acute (hospitalizations, observation stays, and ED visits) and postacute care use across the comorbidity profiles.

      Interpretation

      Distinct comorbidity profiles can be identified in patients with COPD using standard EHR-based diagnostic codes, and these profiles are associated with subsequent acute and postacute care use. Population-based risk stratification schemes for end-to-end, comprehensive COPD management should consider integrating comorbidity profiles such as those found in this study.

      Key Words

      Abbreviations:

      CCI (Charlson Comorbidity Index), EHR (electronic health record), LCA (latent class analysis)
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      References

        • Mannino D.M.
        • Thorn D.
        • Swensen A.
        • Holguin F.
        Prevalence and outcomes of diabetes, hypertension and cardiovascular disease in COPD.
        Eur Respir J. 2008; 32: 962-969
        • Celli B.R.
        • Decramer M.
        • Wedzicha J.A.
        • et al.
        An official American Thoracic Society/European Respiratory Society statement: research questions in COPD.
        Eur Respir Rev. 2015; 24: 159-172
        • Chatila W.M.
        • Thomashow B.M.
        • Minai O.A.
        • Criner G.J.
        • Make B.J.
        Comorbidities in chronic obstructive pulmonary disease.
        Proc Am Thorac Soc. 2008; 5: 549-555
        • Agusti A.
        • Edwards L.D.
        • Rennard S.I.
        • et al.
        Persistent systemic inflammation is associated with poor clinical outcomes in COPD: a novel phenotype.
        PloS One. 2012; 7e37483
        • Soriano J.B.
        • Visick G.T.
        • Muellerova H.
        • Payvandi N.
        • Hansell A.L.
        Patterns of comorbidities in newly diagnosed COPD and asthma in primary care.
        Chest. 2005; 128: 2099-2107
        • Chen W.
        • Thomas J.
        • Sadatsafavi M.
        • FitzGerald J.M.
        Risk of cardiovascular comorbidity in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis.
        Lancet Respir Med. 2015; 3: 631-639
        • DeJean D.
        • Giacomini M.
        • Vanstone M.
        • Brundisini F.
        Patient experiences of depression and anxiety with chronic disease: a systematic review and qualitative meta-synthesis.
        Ont Health Technol Assess Ser. 2013; 13: 1-33
        • Mullerova H.
        • Agusti A.
        • Erqou S.
        • Mapel D.W.
        Cardiovascular comorbidity in COPD: systematic literature review.
        Chest. 2013; 144: 1163-1178
        • Divo M.J.
        • Casanova C.
        • Marin J.M.
        • et al.
        COPD comorbidities network.
        Eur Respir J. 2015; 46: 640-650
        • Vanfleteren L.E.
        • Spruit M.A.
        • Groenen M.
        • et al.
        Clusters of comorbidities based on validated objective measurements and systemic inflammation in patients with chronic obstructive pulmonary disease.
        Am J Respir Crit Care Med. 2013; 187: 728-735
        • Rennard S.I.
        • Locantore N.
        • Delafont B.
        • et al.
        Identification of five chronic obstructive pulmonary disease subgroups with different prognoses in the ECLIPSE cohort using cluster analysis.
        Ann Am Thorac Soc. 2015; 12: 303-312
        • Divo M.
        • Cote C.
        • de Torres J.P.
        • et al.
        Comorbidities and risk of mortality in patients with chronic obstructive pulmonary disease.
        Am J Respir Crit Care Med. 2012; 186: 155-161
        • Chubachi S.
        • Sato M.
        • Kameyama N.
        • et al.
        Identification of five clusters of comorbidities in a longitudinal Japanese chronic obstructive pulmonary disease cohort.
        Respir Med. 2016; 117: 272-279
        • Huber M.B.
        • Wacker M.E.
        • Vogelmeier C.F.
        • Leidl R.
        Excess costs of comorbidities in chronic obstructive pulmonary disease: a systematic review.
        PloS One. 2015; 10e0123292
        • Gershon A.S.
        • Guan J.
        • Victor J.C.
        • Goldstein R.
        • To T.
        Quantifying health services use for chronic obstructive pulmonary disease.
        Am J Respir Crit Care Med. 2013; 187: 596-601
        • Gershon A.S.
        • Mecredy G.C.
        • Guan J.
        • Victor J.C.
        • Goldstein R.
        • To T.
        Quantifying comorbidity in individuals with COPD: a population study.
        Eur Respir J. 2015; 45: 51-59
        • Bilde L.
        • Rud Svenning A.
        • Dollerup J.
        • Baekke Borgeskov H.
        • Lange P.
        The cost of treating patients with COPD in Denmark—a population study of COPD patients compared with non-COPD controls.
        Respir Med. 2007; 101: 539-546
        • Chen W.
        • FitzGerald J.M.
        • Sin D.D.
        • Sadatsafavi M.
        • Canadian Respiratory Research Network
        Excess economic burden of comorbidities in COPD: a 15-year population-based study.
        Eur Respir J. 2017; 50: 1700393
        • Coleman K.J.
        • Ngor E.
        • Reynolds K.
        • et al.
        Initial validation of an exercise “vital sign” in electronic medical records.
        Med Sci Sports Exerc. 2012; 44: 2071-2076
        • Liu I.A.
        • Moy M.L.
        • Estrada E.
        • Rippberger E.
        • Nguyen H.Q.
        An ‘exercise vital sign’ is a valid proxy measure of physical activity in COPD in routine clinical care.
        Translational Journal of the American College of Sports Medicine. 2017; 2: 148-152
        • Moy M.L.
        • Gould M.K.
        • Liu I.A.
        • Lee J.S.
        • Nguyen H.Q.
        Physical activity assessed in routine care predicts mortality after a COPD hospitalisation.
        ERJ Open Res. 2016; 2: 00062-2015
        • Nguyen H.Q.
        • Chu L.
        • Liu I.L.
        • et al.
        Associations between physical activity and 30-day readmission risk in chronic obstructive pulmonary disease.
        Ann Am Thorac Soc. 2014; 11: 695-705
        • Deyo R.A.
        • Cherkin D.C.
        • Ciol M.A.
        Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases.
        J Clin Epidemiol. 1992; 45: 613-619
        • Muthen B.
        Latent variable analysis: growth mixture modeling and related techniques for longitudinal data.
        in: Kaplan D. Handbook of Quantitative Methodology for the Social Sciences. Sage, Newbury Park, CA2004: 345-368
        • Nylund K.L.
        • Asparouhov T.
        • Muthén B.O.
        Deciding on the number of classes in latent class analysis and growth mixture modeling: a Monte Carlo simulation study.
        Structural Equation Modeling. 2007; 14: 535-569
        • Nylund-Gibson K.
        • Choi A.Y.
        Ten frequently asked questions about latent class.
        Transl Issues Psychol Sci. 2018; 4: 440
        • Masyn K.E.
        Latent class analysis and finite mixture modeling.
        in: Little T.D. The Oxford Handbook of Quantitative Methods: Vol. 2. Statistical Analysis. Oxford University Press, New York2013: 551-611
        • Jones P.W.
        • Mullerova H.
        • Agusti A.
        • et al.
        Cardiovascular disease does not predict exacerbation rate or mortality in chronic obstructive pulmonary disease.
        Am J Respir Crit Care Med. 2018; 197: 400-403
        • Axson E.L.
        • Ragutheeswaran K.
        • Sundaram V.
        • et al.
        Hospitalisation and mortality in patients with comorbid COPD and heart failure: a systematic review and meta-analysis.
        Respir Res. 2020; 21: 54
        • Niewoehner D.E.
        • Lokhnygina Y.
        • Rice K.
        • et al.
        Risk indexes for exacerbations and hospitalizations due to COPD.
        Chest. 2007; 131: 20-28
        • Canepa M.
        • Franssen F.M.E.
        • Olschewski H.
        • et al.
        Diagnostic and therapeutic gaps in patients with heart failure and chronic obstructive pulmonary disease.
        JACC Heart Fail. 2019; 7: 823-833
        • Anderson L.
        • Oldridge N.
        • Thompson D.R.
        • et al.
        Exercise-based cardiac rehabilitation for coronary heart disease: Cochrane systematic review and meta-analysis.
        J Am Coll Cardiol. 2016; 67: 1-12
        • Rochester C.L.
        • Vogiatzis I.
        • Holland A.E.
        • et al.
        An Official American Thoracic Society/European Respiratory Society policy statement: enhancing implementation, use, and delivery of pulmonary rehabilitation.
        Am J Respir Crit Care Med. 2015; 192: 1373-1386
        • Petta V.
        • Perlikos F.
        • Loukides S.
        • et al.
        Therapeutic effects of the combination of inhaled beta2-agonists and beta-blockers in COPD patients with cardiovascular disease.
        Heart Fail Rev. 2017; 22: 753-763
        • Lanken P.N.
        • Terry P.B.
        • Delisser H.M.
        • et al.
        An official American Thoracic Society clinical policy statement: palliative care for patients with respiratory diseases and critical illnesses.
        Am J Respir Crit Care Med. 2008; 177: 912-927
      1. Totten AM, White-Chu EF, Wasson N, et al. Home-Based Primary Care Interventions [Internet]. Rockville, MD: Agency for Healthcare Research and Quality (US); 2016 Feb. (Comparative Effectiveness Reviews, No. 164).https://www.ncbi.nlm.nih.gov/books/NBK356253/. Accessed March 22, 2021.

        • Echevarria C.
        • Gray J.
        • Hartley T.
        • et al.
        Home treatment of COPD exacerbation selected by DECAF score: a non-inferiority, randomised controlled trial and economic evaluation.
        Thorax. 2018; 73: 713-722
        • Edes T.
        • Kinosian B.
        • Vuckovic N.H.
        • Nichols L.O.
        • Becker M.M.
        • Hossain M.
        Better access, quality, and cost for clinically complex veterans with home-based primary care.
        J Am Geriatr Soc. 2014; 62: 1954-1961
        • Valluru G.
        • Yudin J.
        • Patterson C.L.
        • et al.
        Integrated home- and community-based services improve community survival among independence at home Medicare beneficiaries without increasing Medicaid costs.
        J Am Geriatr Soc. 2019; 67: 1495-1501
        • Gomes B.
        • Calanzani N.
        • Curiale V.
        • McCrone P.
        • Higginson I.J.
        Effectiveness and cost-effectiveness of home palliative care services for adults with advanced illness and their caregivers.
        Cochrane Database Syst Rev. 2013; Cd007760
        • van Eerd E.A.
        • van der Meer R.M.
        • van Schayck O.C.
        • Kotz D.
        Smoking cessation for people with chronic obstructive pulmonary disease.
        Cochrane Database Syst Rev. 2016; 8: CD010744
        • Ellerbeck E.F.
        • Nollen N.
        • Hutcheson T.D.
        • et al.
        Effect of long-term nicotine replacement therapy vs standard smoking cessation for smokers with chronic lung disease: a randomized clinical trial.
        JAMA Netw Open. 2018; 1e181843
        • Yu T.
        • Ter Riet G.
        • Puhan M.A.
        • Frei A.
        Physical activity and risk of comorbidities in patients with chronic obstructive pulmonary disease: a cohort study.
        NPJ Prim Care Respir Med. 2017; 27: 36
        • Garcia-Aymerich J.
        • Lange P.
        • Benet M.
        • Schnohr P.
        • Anto J.M.
        Regular physical activity modifies smoking-related lung function decline and reduces risk of chronic obstructive pulmonary disease: a population-based cohort study.
        Am J Respir Crit Care Med. 2007; 175: 458-463
        • Moy M.L.
        • Teylan M.
        • Danilack V.A.
        • Gagnon D.R.
        • Garshick E.
        An index of daily step count and systemic inflammation predicts clinical outcomes in chronic obstructive pulmonary disease.
        Ann Am Thorac Soc. 2014; 11: 149-157
        • Sator L.
        • Horner A.
        • Studnicka M.
        • et al.
        Overdiagnosis of COPD in subjects with unobstructed spirometry: a BOLD analysis.
        Chest. 2019; 156: 277-288
        • Lamprecht B.
        • Soriano J.B.
        • Studnicka M.
        • et al.
        Determinants of underdiagnosis of COPD in national and international surveys.
        Chest. 2015; 148: 971-985
        • Gershon A.S.
        • Thiruchelvam D.
        • Chapman K.R.
        • et al.
        Health services burden of undiagnosed and overdiagnosed COPD.
        Chest. 2018; 153: 1336-1346