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      Chronic obstructive pulmonary disease exacerbation frequency and severity

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          Dear editor We read with great interest the original work by Motegi et al1 comparing three multidimensional assessment systems – BODE (body mass index, obstruction, dyspnea, and exercise capacity) index, DOSE (dyspnea, obstruction, smoking, exacerbations) index and ADO (age, dyspnea, obstruction) index – for predicting COPD (chronic obstructive pulmonary disease) exacerbations. In this study, exacerbation rates for the first and second year were 0.57 and 0.48 per patient-year respectively, while previous exacerbations, DOSE index, FEV1% (% forced expiratory volume in 1 second) predicted and long-term oxygen therapy (LTOT) use were shown to be predictors of COPD exacerbations. However, this study seems to have quite different results from our own study that focused on exacerbation frequency and severity. In our study, we examined COPD exacerbations in the general population with the aim of determining potential risk factors. We studied the frequency and severity of COPD exacerbations in patients who visited the Respiratory Medicine Clinic at University of Thessaly Medical School on an outpatient basis between March 2012 and April 2013. Our study included only patients with COPD confirmed by a spirometry test and aged over 40 years. Patients with other respiratory diseases were excluded from the study. All patients took a spirometry test, had their medical history recorded, and a physical examination was performed. In the study 106 patients participated (91.5% male), with an average age of 71.48±8.72 years (mean ± standard deviation), with 40.6% classified as smokers, 56.6% ex-smokers and 2.8% non-smokers. According to GOLD (Global initiative for chronic Obstructive Lung Disease) classification 12.3% of patients were stage I, 39.6% stage II, 34.9% stage III and 13.2% stage IV. 25.5% were assessed in patient group A, 13.2% in group B, 25.5% in group C and 35.8% in group D. In total, 175 exacerbations were recorded (1.65 exacerbations per patient-year). Exacerbation rates were 1.64 for stage I patients, 1.36 for stage II, 1.62 for stage III and 2.69 for stage IV. During the past year 36.8% of the patients reported frequent exacerbations (≥2 per year). Overall, 35.7% of patients with stage I disease, 28.6% of patients with stage II, 35.1% with stage III, and 69.2% with stage IV had frequent exacerbations. According to exacerbation severity, 16.6% were mild, 38.9% were moderate, and 44.6% had severe exacerbations. For the treatment of moderate and severe exacerbations 15.4% visited a doctor, 23.4% visited a primary health center or an emergency department, and 44.6% were hospitalized. The treatment of COPD exacerbations was solely with antibiotics in 42.9% of patients, solely with systemic corticosteroids in 6.5% of patients, and 50.6% of patients were treated with both antibiotics and corticosteroids. The main risk factor for frequent exacerbations was chronic cough (OR [odds ratio]: 2.62; 95% CI [confidence interval]:1.15–5.97; P=0.02), while age, years with COPD, and frequent exacerbations appeared to be associated with severe exacerbations. Our exacerbation rate agrees with Miravitlles et al,2 who mentioned 1.5 COPD exacerbations per patient-year. This study used a symptom-based definition of exacerbation without using daily diaries, such as our study did. Other symptom-based studies, including diaries, have shown higher rates (2.4–2.7).3–5 Our study has shown that a significant percentage of COPD patients experience frequent exacerbations (≥2/year) and corresponds with the ECLIPSE study,6 which also cited similar results. Moreover, most of our patients experienced moderate and severe exacerbations leading to the need for health care, and many of them were finally hospitalized. The epidemiology survey EPIPTOSI7 in Greece also reported significant use of health services for COPD exacerbations, while in other health care systems huge differences were noticed.8 Finally, exacerbation frequency appears to be associated with clinical factors, such as chronic cough, which was also mentioned in the ECLIPSE study,6 but it was not associated with other symptoms or LTOT.

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          The cost of moderate and severe COPD exacerbations to the Canadian healthcare system.

          The cost of exacerbations in chronic obstructive pulmonary disease (COPD) has not been well studied. The aim of this study was to identify and quantify the (average) cost of moderate and severe exacerbations (ME and SE, respectively) from a Canadian perspective. Resources used during ME and SE were identified in a year long prospective, observational study (Resource Utilization Study In COPD (RUSIC)). The units of analysis were ME and SE. Unit costs (2006$CAN), based on provincial, hospital and published sources, were applied to resources. The overall cost per ME and SE were calculated. The population burden of exacerbations was also calculated. Among study participants (N=609, aged 68.6+/-9.4 years, 58.3% male) there were 790 exacerbations: 639 (80.9%) MEs and 151 (19.1%) SEs. Of the 790 exacerbations, 618 (78.2%), 245 (31.0%) and 151 (19.1%) included a visit to an outpatient clinic, emergency department (ED) or hospital, respectively. For ME, 85.9% and 13.1% involved visits to GPs and respirologists, respectively. Pharmacologic treatment changes in the outpatient setting involved antibiotics (63.1%) and corticosteroids (34.7%). The overall mean costs for outpatient and ED services for MEs were $126 (N=574) and $515 (N=105), respectively. The average overall cost of a ME was $641. For SEs, the average hospital stay was 10.0 days. The overall mean costs of outpatient, ED and hospitalization services for SE were $114 (N=44), $774 (N=140) and $8669 (N=151), respectively. The average overall cost of a SE was $9557. The economic burden associated with MEs and especially SEs, in Canada, is considerable and likely has a substantial impact on healthcare costs. The overall burden of exacerbations has been estimated in the range of $646 million to $736 million per annum.
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            Epidemiological survey in primary care patients with chronic obstructive pulmonary disease in Greece; The EPIPTOSI study


              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
              06 November 2013
              : 8
              : 533-535
              Respiratory Medicine Department, University of Thessaly Medical School, University Hospital of Larissa, Larissa, Greece
              [1 ]Department of Pulmonary Medicine and Oncology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
              [2 ]Respiratory Care Clinic, Nippon Medical School, Tokyo, Japan
              [3 ]Respiratory Research Unit, Peninsula Medical School, Plymouth, UK
              Author notes
              Correspondence: Eirini Stafyla, Respiratory Medicine Department, University Hospital of Larissa, Mezourlo, (Biopolis), 41110, Larissa, Greece, Tel +30 24 1350 2896, Fax +30 24 1350 1563, Email eirinistaf@
              © 2013 Stafyla et al. This work is published by Dove Medical Press Limited, and licensed under Creative Commons Attribution – Non Commercial (unported, v3.0) License

              The full terms of the License are available at Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.


              Respiratory medicine


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