Predictors of Rehospitalization and Death After a Severe Exacerbation of COPD

doi:10.1378/chest.06-3018

Chest

Volume 132, Issue 6, December 2007, Pages 1748-1755

https://doi.org/10.1378/chest.06-3018 Get rights and content

Background

Patients who survive a severe exacerbation of COPD are at high risk of rehospitalization for COPD and death. The objective of this study was to determine predictors of these events in a large cohort of Veterans Affairs (VA) patients.

Methods

We identified 51,353 patients who were discharged after an exacerbation of COPD in the VA health-care system from 1999 to 2003, and determined the rates of rehospitalization for COPD and death from all causes. Potential risk factors were assessed with univariate and multivariate survival analysis.

Results

On average, the cohort was elderly (mean age, 69 years), predominately white (78% white, 13% black, 3% other, and 6% unknown), and male (97%), consistent with the underlying VA population. The risk of death was 21% at 1 year, and 55% at 5 years. Independent risk factors for death were age, male gender, prior hospitalizations, and comorbidities including weight loss and pulmonary hypertension; nonwhite race and other comorbidities (asthma, hypertension, and obesity) were associated with decreased mortality. The risk of rehospitalization for COPD was 25% at 1 year, and 44% at 5 years, and was increased by age, male gender, prior hospitalizations, and comorbidities including asthma and pulmonary hypertension. Hispanic ethnicity and other comorbidities (diabetes and hypertension) were associated with a decreased risk of rehospitalization.

Conclusions

Age, male gender, prior hospitalizations, and certain comorbid conditions were risk factors for death and rehospitalization in patients discharged after a severe COPD exacerbation. Nonwhite race and other comorbidities were associated with decreased risk.

Section snippets

Human Subjects

Approval for this study was obtained from the Colorado Multiple Institutional Review Board and the VA Eastern Colorado Healthcare System Research and Development Committee. No personally identifiable information was used.

Inpatient Administrative Data:

Data on inpatient stays were obtained from the Veteran Healthcare Administration medical SAS inpatient data sets (SAS Institute; Cary, NC), also known as the patient treatment file (PTF). The PTF is an SAS database extracted from the National Patient Care Database and

Cohort Selection

We identified 54,269 patients with COPD as their primary discharge diagnosis and/or DRG in the study period; 51,353 patients were eligible for analysis. Exclusions are outlined in Figure 1. The primary reason for exclusion was death during the index stay, which occurred in 3.5% of index stays. Invalid data were present for 33 patients who were excluded (28 patients for death dates prior to the index hospitalization, and 5 patients for overlapping stays).

Descriptive Statistics

The majority of the patients were white,

Discussion

This report details the clinical outcomes of a large cohort of VA patients after hospitalization for a severe exacerbation of COPD. We demonstrate a significant risk of subsequent severe exacerbations and death in this population. The mortality rates described in this article are similar to those in other cohorts of unselected patients after hospitalization for COPD.⁷¹⁰ The mortality rates we found are higher than those in previous pharmacoepidemiologic studies²³²⁴²⁵ using large administrative

Conclusion

Age, gender, race/ethnicity, prior health-care utilization, and comorbid conditions were important modifiers of the risk of death and rehospitalization in this cohort of patients discharged after a severe exacerbation of COPD. Future work should explore potentially modifiable risk factors, and should examine these findings in databases with more detailed clinical information.

Acknowledgments

The authors thank Drs. Phoebe Barton and Lee Newman (review of Master's thesis); Drs. Andy Kramer and James Murphy (advice on modeling); Dr. Todd Lee (help with VA data); and Angela Keniston (assistance with figures).

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Portions of this manuscript have been presented in abstract form at the 24th Annual Epidemiologic Research Exchange, Denver, CO, February 24, 2006; at the American Thoracic Society International Conference, San Diego, CA, May 24, 2006; and at the Third Annual Respiratory Disease Young Investigator's Forum, Boston, MA, October 7, 2006.

This work was performed at the University of Colorado Health Sciences Center.

This work as supported by the Flight Attendant's Medical Research Institute Young Clinical Scientist Award (052390); the National Institutes of Health Clinical Research Loan Repayment Program; NRSA 2 T32 HL 007085; US Department of Veteran's Affairs Colorado REAP to Improve Care Coordination-REA 06-173; University of Colorado Health Sciences Center, Division of Pulmonary Sciences and Critical Care Medicine; the COPD Clinical Research Network Clinical Research Skills Development Core; and the Hartford/Jahnigen Center of Excellence in Geriatrics.

Dr. Sutherland has served as an advisor or consultant to Dey, GlaxoSmithKline, Pfizer, Talecris, and Schering-Plough; has received speaking honoraria from IVAX; and has received unrestricted investigator-initiated grant funding from Boehringer Ingelheim and GlaxoSmithKline. Drs. McGhan, Radcliff, Welsh, and Make, and Mr. Fish report no financial or other potential conflicts of interest.

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Chest

Original ResearchCOPDPredictors of Rehospitalization and Death After a Severe Exacerbation of COPD

Background

Methods

Results

Conclusions

Section snippets

Human Subjects

Inpatient Administrative Data:

Cohort Selection

Descriptive Statistics

Discussion

Conclusion

Acknowledgments

Chest

Respir Med

Chest

Chest

Chest

Respir Med

Respir Med

Respir Med

Chest

Chest

J Clin Epidemiol

J Chron Dis

Respir Med

Chest

Respir Med

Morbidity and mortality: 2002 chartbook on cardiovascular, lung, and blood diseases. Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, May 2002

Evidence-based health policy: lessons from the Global Burden of Disease Study

Science

Bacteria in exacerbations of chronic obstructive pulmonary disease: phenomenon or epiphenomenon?

Proc Am Thorac Soc

In-hospital mortality following acute exacerbations of chronic obstructive pulmonary disease

Arch Intern Med

Outcomes following acute exacerbation of severe chronic obstructive lung disease

Am J Respir Crit Care Med

Original Research
COPD
Predictors of Rehospitalization and Death After a Severe Exacerbation of COPD