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      Prediction models for exacerbations in different COPD patient populations: comparing results of five large data sources

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          Background and objectives

          Exacerbations are important outcomes in COPD both from a clinical and an economic perspective. Most studies investigating predictors of exacerbations were performed in COPD patients participating in pharmacological clinical trials who usually have moderate to severe airflow obstruction. This study was aimed to investigate whether predictors of COPD exacerbations depend on the COPD population studied.


          A network of COPD health economic modelers used data from five COPD data sources – two population-based studies (COPDGene ® and The Obstructive Lung Disease in Norrbotten), one primary care study (RECODE), and two studies in secondary care (Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoint and UPLIFT) – to estimate and validate several prediction models for total and severe exacerbations (= hospitalization). The models differed in terms of predictors (depending on availability) and type of model.


          FEV 1% predicted and previous exacerbations were significant predictors of total exacerbations in all five data sources. Disease-specific quality of life and gender were predictors in four out of four and three out of five data sources, respectively. Age was significant only in the two studies including secondary care patients. Other significant predictors of total exacerbations available in one database were: presence of cough and wheeze, pack-years, 6-min walking distance, inhaled corticosteroid use, and oxygen saturation. Predictors of severe exacerbations were in general the same as for total exacerbations, but in addition low body mass index, cardiovascular disease, and emphysema were significant predictors of hospitalization for an exacerbation in secondary care patients.


          FEV 1% predicted, previous exacerbations, and disease-specific quality of life were predictors of exacerbations in patients regardless of their COPD severity, while age, low body mass index, cardiovascular disease, and emphysema seem to be predictors in secondary care patients only.

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          Most cited references 19

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          The costs of exacerbations in chronic obstructive pulmonary disease (COPD).

          Exacerbations are the key drivers in the costs of chronic obstructive pulmonary disease (COPD). The objective was to examine the costs of COPD exacerbations in relation to differing degrees of severity of exacerbations and of COPD. We identified 202 subjects with COPD, defined according to the BTS and ERS criteria. Exacerbations were divided into mild (self-managed), mild/moderate (telephone contact with a health-care centre and/or the use of antibiotics/systemic corticosteroids), moderate (health-care centre visits) and severe (emergency care visit or hospital admission). Exacerbations were identified by sending the subjects a letter inquiring whether they had any additional respiratory problems or influenza the previous winter. At least one exacerbation was reported by 61 subjects, who were then interviewed about resource use for these events. The average health-care costs per exacerbation were SEK 120 (95% C=39-246), SEK 354 (252-475), SEK 2111 (1673-2612) and SEK 21852 (14436-29825) for mild, mild/moderate, moderate and severe exacerbations, respectively. Subjects with impaired lung function experienced more severe exacerbations, which was also reflected in the cost of exacerbations per severity of the disease during the 4 1/2 month study period (ranging from SEK 224 for mild to SEK 13708 for severe cases, median SEK 940). Exacerbations account for 35-45% of the total per capita health-care costs for COPD. In conclusion, costs varied considerably with the severity of the exacerbation as well as with the severity of COPD. The prevention of moderate-to-severe exacerbations could be very cost-effective and improve the quality of life.
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            Prevention of acute exacerbations of COPD: American College of Chest Physicians and Canadian Thoracic Society Guideline.

            COPD is a major cause of morbidity and mortality in the United States as well as throughout the rest of the world. An exacerbation of COPD (periodic escalations of symptoms of cough, dyspnea, and sputum production) is a major contributor to worsening lung function, impairment in quality of life, need for urgent care or hospitalization, and cost of care in COPD. Research conducted over the past decade has contributed much to our current understanding of the pathogenesis and treatment of COPD. Additionally, an evolving literature has accumulated about the prevention of acute exacerbations.
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              Gender differences in health care expenditures, resource utilization, and quality of care.

               G. Owens (2008)
              Rising health care costs and quality of care concerns require a re-evaluation of various aspects of health care delivery. In order to properly manage costs, payers need to understand how different patient populations contribute to spending trends and where suboptimal quality of care is more prevalent, and, therefore, may drive cost trends. To demonstrate significant opportunities for improvement in the management of postmenopausal women by highlighting areas of imbalance between health care costs and quality of care. Women tend to use significantly more services and spend more health care dollars than men. The greatest disparity in health care spending between men and women has been noted in the population aged 45 to 64 years. In this age group, women's health issues primarily revolve around chronic conditions and menopausal symptoms. With the onset of menopause, the risk of cardiovascular disease (CVD), breast cancer, and osteoporosis increases significantly. However, substantial evidence indicates that there are broad gaps in the quality of care received by postmenopausal women. In some populations, breast cancer screening rates are almost 20% below the national target. Stratification of health plan performance with the National Committee for Quality Assurance/Health Care Effectiveness Data and Information Set (NCQA/HEDIS) measures related to CVD demonstrates gender-based gaps, even when there are no disparities in access to care. The widest gender gap in CVD management is observed with low-density lipoprotein (LDL) cholesterol control rates. In the management of postmenopausal women with a history of fractures, standards of care are met only 19% to 50% of the time. After the age of 45, the majority of women either do not receive any information about menopause from their physicians or they are unsatisfied with the menopause counseling that they do receive. These quality gaps should be considered in light of the high prevalence of chronic illness and costs attributed to these conditions and menopausal symptoms in women. When reviewing strategies for reducing health care costs, managed care organizations (MCOs) should focus on the management of postmenopausal women. With the use of proper screening, preventive care, and therapeutic management in postmenopausal women, an MCO could potentially achieve downstream reduction in overall costs for this population.

                Author and article information

                Int J Chron Obstruct Pulmon Dis
                Int J Chron Obstruct Pulmon Dis
                International Journal of COPD
                International Journal of Chronic Obstructive Pulmonary Disease
                Dove Medical Press
                01 November 2017
                : 12
                : 3183-3194
                [1 ]Institute for Medical Technology Assessment (iMTA)/Erasmus School of Health Policy & Management (ESHPM), Erasmus University Rotterdam, Rotterdam, the Netherlands
                [2 ]Department for Prevention and Health Services Research, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
                [3 ]Department of Epidemiology, Groningen University, University Medical Centre Groningen, Groningen, the Netherlands
                [4 ]Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
                [5 ]Health Economics Unit, Department of Clinical Sciences Malmö, Lund University, Lund, Sweden
                [6 ]Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine, The OLIN Unit, Umeå University, Umeå, Sweden
                [7 ]ICON Health Economics, Toronto, Canada
                [8 ]Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, MD, USA
                Author notes
                Correspondence: Martine Hoogendoorn, Institute for Medical Technology Assessment (iMTA)/Erasmus School of Health Policy & Management (ESHPM), Erasmus University Rotterdam, PO Box 1738, 3000 DR Rotterdam, the Netherlands, Tel +31 10 408 8871, Email hoogendoorn@
                © 2017 Hoogendoorn et al. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

                Original Research

                Respiratory medicine

                copd, exacerbations, modeling, hospitalizations, validation


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