How Do Comorbidities Affect Treatment for Patients With COPD?

Hospital readmissions are a cause of morbidity and mortality among patients with chronic obstructive pulmonary disease (COPD); however, it is unknown how such comorbidities affect treatment choices. Recent research suggested that comorbidity was associated with 30-day readmission and mortality, and with delivery of fewer treatments known to be beneficial among patients with COPD.

The study involved veterans hospitalized with a COPD exacerbation among 6 Veterans Affairs hospitals between 2005 to 2011. The researchers collected data of the comorbidities during the year before hospitalization. Also, the Deyo-Charlson index was used to measure the burden of comorbidity.

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“We defined the primary outcome as all-cause mortality or readmission within thirty days of discharge from index hospitalization,” the authors stated. “We also sought to examine whether comorbidity would be associated with delivery of systemic corticosteroids and antibiotics during the index hospital admission, two therapies that are generally recommended for treatment of COPD exacerbations among hospitalized patients.”

In total, 2391 patients were included in the study. The researchers found that each 1-point increase in the Charlson index was associated with greater odds of readmission or death, yet had reduced odds of receiving treatment with steroids and antibiotics. Additionally, patients with comorbid congestive heart failure, coronary artery disease, and chronic kidney disease were less likely to receive corticosteroids and antibiotic treatment than those without those specific comorbidities.

“We found that comorbidity was associated with the delivery of fewer treatments for COPD exacerbations, which is a novel finding,” the authors explained. “The relationship between comorbidity and readmission risk has been thought of as a non-modifiable issue of overall increased severity of illness. However, our study suggests that one potential explanation may be that comorbidity may also be a driver of care quality, as patients with increased comorbidity receive fewer treatments with oral corticosteroids and antibiotics.”

The researchers suggested that the underuse of treatments for COPD exacerbations may be attributed to the following potential explanations:

• Increased comorbidity is associated with increased overall treatment complexity and may lead to poorer quality of COPD care management.
• Clinicians may have wanted to avoid, or patients may have previously experienced, unwanted side effects of COPD treatments.
• Patients with multiple comorbidities and etiologies for dyspnea and respiratory symptoms may lead to diagnostic uncertainty or misclassification of disease.

“Our findings could also provide insight into future quality improvement strategies to better understand this disparity among the patients with COPD, as well as encourage reassessment of the adjustments performed in the CMS COPD penalty for comorbidities,” concluded the authors.

The authors noted that their study opens up a target for additional future studies in order to gain more insight into the readmission and mortality rates for those experiencing COPD exacerbations.

Reference

Spece LJ, Epler EM, Donovan LM, et al. Role of Comorbidities in Treatment and Outcomes after Chronic Obstructive Pulmonary

Disease Exacerbations. [published online August 4, 2918]. Ann Am Thorac Soc. doi:10.1513AnnalsATS.201804-255OC.