Comorbilidades en pacientes hospitalizados por enfermedad pulmonar obstructiva crónica. Análisis comparativo de los estudios ECCO y ESMI

doi:10.1016/j.rce.2012.02.014

Revista Clínica Española

Volume 212, Issue 6, June 2012, Pages 281-286

https://doi.org/10.1016/j.rce.2012.02.014 Get rights and content

Resumen

Antecedentes y objetivos

La presencia de enfermedades asociadas es muy frecuente en los pacientes hospitalizados por exacerbación de EPOC. Hemos estudiado las comorbilidades de pacientes ingresados por la enfermedad en los servicios de Medicina Interna españoles y hemos valorado las variaciones con respecto a un estudio previo (estudio ECCO), realizado 2 años antes.

Pacientes y métodos

Estudio de cohortes, transversal y multicéntrico. Se incluyeron pacientes hospitalizados por exacerbación de EPOC en los servicios de Medicina Interna españoles. A todos los pacientes se les estudió la presencia de comorbilidades mediante el índice de Charlson y un cuestionario con afecciones relevantes no incluidas en este índice. Además, se recogieron datos espirométricos, sobre la duración de la enfermedad o el tratamiento domiciliario, entre otras variables.

Resultados

Se estudiaron 1.004 pacientes (398 en el estudio ECCO y 606 en el ESMI), un 89,4% eran varones, con una edad media de 73 años (DE: 9,5 años). Los pacientes del estudio ESMI obtuvieron mayores puntuaciones en el índice de Charlson (3,04 vs. 2,71; p < 0,01), y presentaron una mayor prevalencia de cardiopatía isquémica (17 vs. 22,0%; p < 0,05), insuficiencia cardiaca (26,9 vs. 35,5%; p < 0,002), enfermedad vascular periférica (12,6 vs. 17,4%; p < 0,02), hipertensión arterial (54,8 vs. 65,6%; p < 0,001), diabetes mellitus (29,4 vs. 37%; p < 0,02) e insuficiencia renal (6,5 vs. 16,8%; p < 0,0001).

Conclusiones

Este estudio confirma la elevada prevalencia de enfermedades asociadas en los pacientes con EPOC que ingresan en los servicios de Medicina Interna españoles, así como el aumento de comorbilidades.

Abstract

Backgrounds and objectives

The presence of associated diseases is very frequent in patients hospitalized due to exacerbation of COPD. We have studied the comorbidities of patients admitted due to the disease in the Spanish Internal Medicine Services and we have evaluated the variations in regards to a previous study (ECCO study) performed two years earlier.

Patients and methods

A cross-sectional, multicenter and cohort study was performed. Patients hospitalized due to exacerbation of COPD in Spanish Internal Medicine Services were enrolled. All the patients were studied for the presence of comorbidity using the Charlson index and a questionnaire with relevant conditions not included in this index. Furthermore, spirometric data were collected on the duration of the disease or home treatment, among other variables.

Results

A total of 1004 patients (398 in the ECCO study and 606 in the ESMI study) were studied. Of these, 89.4% were males, with mean age of 73 years (SD: 9.5 years). The patients of the ESMI study obtain higher scores on the Charlson index (3.04 vs. 2.71; P<0.01), and had a greater prevalence of ischemic heart disease (17 vs. 22.0%; P<0.05), heart failure (26.9 vs. 35.5%; P<.002), peripheral vascular disease (12.6 vs. 17.4%; P<.02), arterial hypertension (54.8 vs. 65.6%; P<.001), diabetes mellitus (29.4 vs. 37%; P<.02) and renal failure (6.5 vs. 16.8%; P<.0001).

Conclusions

This study confirms the elevated prevalence of associated diseases in patients with COPD who are admitted to the Spanish Internal Medicine Services and the increase of comorbidities.

Section snippets

Introducción

La enfermedad pulmonar obstructiva crónica (EPOC) es una de las afecciones más frecuentes que originan mayor morbimortalidad. Las previsiones son que su impacto continuará aumentando hasta convertirse en el año 2020 en la tercera causa de mortalidad y de años de vida perdidos a nivel mundial¹. En nuestro país la EPOC afecta a un 10% de la población² y es la quinta causa de mortalidad³. Los pacientes con EPOC presentan más frecuentemente que la población general otras afecciones asociadas, que

Selección de pacientes y métodos

Ambos estudios, ECCO (Estudio de Comorbilidad en pacientes EPOC hospitalizados en servicios de Medicina Interna) y ESMI (EPOC en los servicios de Medicina Interna), comparten un diseño multicéntrico, transversal y observacional. El estudio ECCO se realizó en 26 centros hospitalarios de nuestro país durante los meses de enero 2007 a diciembre 2008, mientras que el estudio ESMI incluyó pacientes entre los meses de octubre 2009 a octubre 2010 y contó con la participación de 70 hospitales

Resultados

De los 503 registros iniciales del estudio ECCO, se analizaron 398 enfermos. En el estudio ESMI se incluyeron al inicio 679 enfermos y se han analizado un total de 606 pacientes (fig. 1). El 97% ingresaron en servicios de Medicina Interna. No existían diferencias entre los pacientes incluidos y excluidos respecto a la edad, el sexo, el historial de tabaquismo o la escala de disnea medida por el mMRC (datos no mostrados).

En conjunto se analizaron los datos de 1.004 pacientes, de los cuales un

Discusión

Este estudio confirma la elevada prevalencia de comorbilidades en los pacientes hospitalizados en los servicios de Medicina Interna españoles por exacerbación de EPOC, con un aumento de estas enfermedades asociadas en el estudio más reciente (ESMI) al compararlo con el previo (ECCO). Entre las afecciones asociadas más frecuentes destaca el incremento de las enfermedades cardiovasculares: cardiopatía isquémica (22 vs. 17%) e infarto de miocardio (12 vs. 8,5%), así como la enfermedad arterial

Conflicto de intereses

Los autores declaran no tener ningún conflicto de intereses.

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Cited by (23)

Clinical Management of COPD in a Real-World Setting. A Big Data Analysis
2021, Archivos de Bronconeumologia
El objetivo de este estudio es evaluar la calidad del diagnóstico y el tratamiento de la EPOC utilizando metodología de big data mediante la plataforma clínica Savana Manager 2.1.
Sobre una población de 1.219.749 sujetos mayores de 40 años se incluyó a 59.369 pacientes con un diagnóstico de EPOC.
El 78% de ellos eran varones. Solo 26.453 (43,5%) disponían de espirometría. En 18.172 pacientes se hizo una aproximación a la gravedad de su proceso: 4.396 leves, 7.100 moderados y 6.676 graves, aunque solo disponían de espirometría obstructiva el 27, el 34 y el 28%, respectivamente.
El manejo clínico de la EPOC recae fundamentalmente en Atención Primaria y Neumología, con un papel relevante de Medicina Interna y, en menor medida, de Geriatría. El tratamiento farmacológico está basado en el uso de broncodilatadores y corticoides inhalados (CI). Se observa un marcado descenso en la utilización de los beta-2-agonistas de larga duración (LABA) en monoterapia y una leve reducción de combinaciones de CI/LABA, asociados a un LAMA en el 74% de los casos.
La mortalidad hospitalaria por cualquier causa de la población global fue del 5,60% frente al 1% de la población general mayor de 40 años. El 35% presentó un ingreso hospitalario, con una estancia media de 6,6 días y una tasa de mortalidad hospitalaria en este grupo del 10,74%.
Este estudio identifica cuáles son las principales características de una población no seleccionada de EPOC y cuáles son los principales errores en el manejo de la enfermedad.
The aim of this study was to evaluate the quality of diagnosis and treatment of COPD using Big Data methodology on the Savana Manager 2.1 clinical platform.
A total of 59,369 patients with a diagnosis of COPD were included from a population of 1,219,749 adults over 40 years of age.
In total, 78% were men. Spirometry data were available for only 26,453 (43.5%) subjects. Disease severity was classified in 18,172 patients: 4,396 mild, 7,100 moderate, and 6,676 severe, although only 27%, 34%, and 28%, respectively, presented obstructive spirometry.
The clinical management of COPD is mainly the responsibility of the primary care and pulmonology departments, while internal medicine and, to a lesser extent, geriatrics also participate. Drug treatment was based on bronchodilators and inhaled corticosteroids (ICS). A marked decline in the use of long-acting beta-2 agonists (LABA) in monotherapy and a slight reduction in ICS/LABA combinations, associated with a LAMA in 74% of cases, was observed.
All-cause in-hospital mortality among the overall population was 5.6% compared to 1% of the general population older than 40 years. In total, 35% were admitted to hospital, with an average stay of 6.6 days and a rate of hospital mortality in this group of 10.74%.
This study identifies the main features of an unselected COPD population and the major errors made in the management of the disease.
Social and clinical predictors associated with prolonged hospital stays for patients with severe exacerbation of chronic obstructive pulmonary disease
2020, Revista Clinica Espanola
Analizar si existen factores sociales que influyan en la estancia hospitalaria prolongada (EHP) de pacientes con agudización grave de EPOC (AEPOC), además de factores clínico-demográficos.
Estudio de cohortes prospectivo. Se incluyeron pacientes consecutivos que ingresaron por AEPOC en un servicio de Neumología. Se registraron variables demográficas, clínicas (tabaquismo, exacerbaciones e infecciones, disnea, impacto según cuestionario CAT, función pulmonar, comorbilidades, oxigenoterapia y ventilación no invasiva) y sociales (situación económica, disponibilidad y sobrecarga de cuidador, dependencia en actividades básicas e instrumentales, riesgo social y uso de servicios sociales), utilizando cuestionarios e índices como Barthel, Lawton-Brody, Zarit, Barber y Gijón. Se realizó un análisis univariante y multivariante mediante un modelo de regresión logística.
Se incluyeron 253 pacientes, y la edad media fue de 68,9 ± 9,8 años. El 77,1% fueron varones. En el modelo de regresión logística se incluyeron tabaquismo activo, valor del FEV₁, puntuación en CAT > 10, disnea 3-4 de la mMRC, presencia de gérmenes en cultivos de esputo, comorbilidad cardiovascular, anemia, oxigenoterapia domiciliaria, vivir solo, residencia en zona rural, sobrecarga del cuidador y la detección de riesgo/problema sociofamiliar. Las variables que se asociaron de forma independiente con la posibilidad de una EHP fueron la puntuación en cuestionario CAT > 10 (OR = 8,9; p = 0,04) y la detección de riesgo/problema sociofamiliar (OR = 2,6; p = 0,04). Fumar activamente fue predictor de estancia más breve (OR = 0,15; p = 0,002).
Variables relacionadas con la esfera social juegan un papel relevante en la estancia hospitalaria, además del impacto de la enfermedad y la persistencia del tabaquismo en pacientes con AEPOC graves.
To determine whether there are social factors that affect the prolonged hospital stay (PHS) of patients with severe chronic obstructive pulmonary disease exacerbation (COPDE), as well as clinical-demographic factors.
We conducted a prospective cohort study that consecutively included patients who were admitted to a Pneumology department for COPDE. We recorded demographic, clinical (tobacco use, exacerbations and infections, dyspnoea, impact according to CAT questionnaire, pulmonary function, comorbidities, oxygen therapy and noninvasive ventilation) and social (financial status, caregiver availability and overload, dependence for basic and instrumental activities, social risk and use of social services) variables, employing questionnaires and indices such as Barthel, Lawton-Brody, Zarit, Barber and Gijón. We performed a univariate and multivariate analysis using a logistic regression model.
The study included 253 patients, with a mean age of 68.9 ± 9.8 years; 77.1% of whom were men. The logistic regression model included active tobacco use, FEV₁ value, CAT score > 10, dyspnoea 3-4 on the MMRC, the presence of bacteria in sputum cultures, cardiovascular comorbidity, anaemia, home oxygen therapy, living alone, rural residence, caregiver overload and detecting social-family risks/problems. The variables independently associated with the possibility of PHS were a CAT score > 10 (OR, 8.9; P = .04) and detecting a social-family risk/problem (OR, 2.6; P = .04). Active smoking was a predictor of shorter stays (OR, 0.15; P = .002).
Variables related to the social sphere play a relevant role in hospital stays, as do the impact of the disease and the persistent use of tobacco by patients with severe COPD exacerbation.
Long-term general and cardiovascular safety of tiotropium/olodaterol in patients with moderate to very severe chronic obstructive pulmonary disease
2017, Respiratory Medicine
Citation Excerpt :
Cardiovascular safety is of particular interest, given the potential effects associated with both of these drug classes [1–3]. Cardiovascular diseases are among the most frequent serious co-morbid conditions in this patient population [4–7] and patients with COPD are at substantially greater risk of developing incident cardiac arrhythmia, thromboembolic disorders, myocardial infarction and stroke compared to healthy individuals [8,9]. Recent evidence from clinical studies of the safety and tolerability profile of LABAs supports their long-term use in COPD including those patients with a history, or increased risk, of cardiovascular disease, when given alone or as a fixed-dose combination with an inhaled corticosteroid [10,11].
Long-term safety, particularly cardiovascular safety, is of special interest in maintenance treatment of chronic obstructive pulmonary disease (COPD) with long-acting β₂-agonists and long-acting muscarinic antagonists, given potential cardiovascular effects.
Two 52-week Phase III trials (TONADO^®) investigated tiotropium/olodaterol (5/5 and 2.5/5 μg) versus tiotropium 2.5, 5 μg and olodaterol 5 μg. In a pre-specified safety analysis, investigator-reported treatment-emergent adverse events (AEs), electrocardiogram and laboratory data were pooled. All serious AE (SAE) reports were reviewed by an independent Adjudication Committee, which assessed whether deaths, hospitalisations or intubations were respiratory, cardiovascular, cerebrovascular or other disease related. Subgroup analyses investigated cardiovascular safety including major cardiac events in patients with cardiovascular co-morbidities.
This analysis comprised 3100 patients with moderate to very severe COPD, treated for ≤1 year, including 784 patients with cardiovascular co-morbidities. AEs were balanced across treatments in the total population as well as in patient subgroups with pre-existing cardiovascular co-morbidities. The incidence and nature of events were consistent with the disease under study and a 1-year trial duration. 494/3100 patients contributed to an adjudicated analysis of SAEs: 260 had respiratory-related, 53 had cardiovascular-related and 16 had cerebrovascular-related SAEs. Incidences of these SAEs were comparable between treatments. There was no evidence of any increased risk for the combination compared to the monotherapy groups.
These data provide confidence for clinicians that tiotropium/olodaterol 5/5 μg can be safely administered once-daily to patients with moderate to very severe COPD long-term, including those with significant cardiovascular co-morbidity.
ClinicalTrials.gov, Nos.: NCT01431274, NCT01431287.
Prognostic assessment of mortality and hospitalizations of outpatients with advanced chronic obstructive pulmonary disease. Usefulness of the CODEX index
2015, Revista Clinica Espanola
Validar el índice CODEX en pacientes ambulatorios con EPOC avanzada.
Se estudió a todos los pacientes con EPOC controlados en una unidad de pacientes crónicos respiratorios. Se calcularon los índices BODEX y CODEX y su relación con mortalidad, hospitalizaciones o ambas, y se realizó un análisis por número de eventos (mortalidad o reingresos), mediante el análisis de riesgos proporcionales de Cox.
Se incluyó a 80 pacientes (90% varones) con una edad media de 73,4 años. El seguimiento medio fue de 656 días con un rango intercuartílico (25-75%) de 417-642 días. Un total de 17 pacientes fallecieron (21%) y 57 (71,3%) requirieron hospitalización por EPOC. El índice CODEX se relacionó significativamente con la mortalidad (p < 0,008; HR: 1,56; IC 95%: 1,1-2,15), el ingreso hospitalario (p < 0,01; HR: 1,35; IC 95%: 1,13-1,62) y la variable combinada (p < 0,03; HR: 1,27; IC 95%: 1,1-1,5). El BODEX no se asoció con la mortalidad (p = 0,17), pero sí con los ingresos (p < 0,001; HR: 1,4; IC 95%: 1,15-1,73) y la variable combinada (p < 0,03; HR: 1,2; IC 95%: 1,02-1,34). Durante el seguimiento se produjeron 187 eventos. Tanto el índice CODEX (p < 0,001; HR:1,17; IC 95%:1,1-1,27) como el BODEX (p < 0,02; HR: 1,12; IC 95%: 1,02-1,23) se relacionaron con el número de eventos, aunque tras ajustar por la interacción entre ambos índices solo el CODEX conservó la significación estadística para la variable combinada por pacientes (p < 0,03) y en el análisis por número de eventos (p < 0,001).
Tanto el CODEX como el BODEX son útiles en la predicción de ingresos hospitalarios, aunque la capacidad pronóstica del CODEX es superior al BODEX tanto en mortalidad como en ingresos hospitalarios.
To validate the CODEX index in outpatients with advanced chronic obstructive pulmonary disease (COPD).
We studied all patients with COPD treated in a chronic respiratory disease unit. We calculated the BODEX and CODEX indices and their relationship with mortality, hospitalisations or both and performed an analysis by number of events (mortality and/or readmissions), using the Cox proportional hazards analysis.
We included 80 patients (90% men) with a mean age of 73.4 years. The mean follow-up was 656 days, with an interquartile range (25-75%) of 417-642 days. Seventeen patients died (21%) and 57 (71.3%) required hospitalisation for COPD. The CODEX index was significantly related to mortality (P<.008; HR: 1.56; 95% CI: 1.1–2.15), hospitalisations (P<.01; HR: 1.35; 95% CI: 1.13–1.62) and the combined variable (P<.03; HR: 1.27; 95% CI: 1.1–1.5). The BODEX index was not associated with mortality (P=.17) but was associated with hospitalisation (P<.001; HR: 1.4; 95% CI: 1.15–1.73) and the combined variable (P<.03; HR: 1.2; 95% CI: 1.02–1.34). There were 187 events during follow-up. Both the CODEX (P<.001; HR: 1.17; 95% CI: 1.1–1.27) and BODEX (P<.02; HR: 1.12; 95% CI: 1.02–1.23) indices were related to the number of events. However, after adjusting for the interaction between the 2 indices, only the CODEX index maintained statistical significance for the combined variable for patients (P<.03) and in the analysis by number of events (P<.001).
Both the CODEX and BODEX indices are useful for predicting hospitalisations, although the prognostic ability of the CODEX index is greater than that of the BODEX index, both for mortality and hospitalisations.
Short- and Medium-term Prognosis in Patients Hospitalized for COPD Exacerbation: The CODEX Index
2014, Chest
Citation Excerpt :
Investigators included the first 10 consecutive patients seen for a severe COPD exacerbation during a 1-year period (October 2009-October 2010). Full methodology is available elsewhere and is summarized in e-Appendix 1.16,17 During admission, all patients were evaluated using a standardized questionnaire.
No valid tools exist for evaluating the prognosis in the short and medium term after hospital discharge of patients with COPD. Our hypothesis was that a new index based on the CODEX (comorbidity, obstruction, dyspnea, and previous severe exacerbations) index can accurately predict mortality, hospital readmission, and their combination for the period from 3 months to 1 year after discharge in patients hospitalized for COPD.
A multicenter study of patients hospitalized for COPD exacerbations was used to develop the CODEX index, and a different patient cohort was used for validation. Comorbidity was measured using the age-adjusted Charlson index, whereas dyspnea, obstruction, and severe exacerbations were calculated according to BODEX (BMI, airflow obstruction, dyspnea, and previous severe exacerbations) thresholds. Information about mortality and readmissions for COPD or other causes was collected at 3 and 12 months after hospital discharge.
Two sets of 606 and 377 patients were included in the development and validation cohorts, respectively. The CODEX index was associated with mortality at 3 months (P < .0001; hazard ratio [HR], 1.5; 95% CI, 1.2-1.8) and 1 year (P < .0001; HR, 1.3; 95% CI, 1.2-1.5), hospital readmissions in the same periods, and their combination (all P < .0001). All CODEX C statistics were superior to those of the BODEX, DOSE (dyspnea, airflow obstruction, smoking status, and exacerbation frequency), and updated ADO (age, dyspnea, and airflow obstruction) indexes.
The CODEX index was a useful predictor of survival and readmission at both 3 months and 1 year after hospital discharge for a COPD exacerbation, with a prognostic capacity superior to other previously published indexes.
Response
2014, Chest

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^◊: Más información sobre los componentes del Estudio ESMI está disponible en el Anexo 1.

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OriginalComorbilidades en pacientes hospitalizados por enfermedad pulmonar obstructiva crónica. Análisis comparativo de los estudios ECCO y ESMIComorbidities in patients hospitalized due to chronic obstructive pulmonary disease. A comparative analysis of the ECCO and ESMI studies

Resumen

Antecedentes y objetivos

Pacientes y métodos

Resultados

Conclusiones

Abstract

Backgrounds and objectives

Patients and methods

Results

Conclusions

Section snippets

Introducción

Selección de pacientes y métodos

Resultados

Discusión

Conflicto de intereses

Chest

Rev Clin Esp

Lancet

Chest

Arch Bronconeumol

J Chronic Dis

Respir Med

Chest

Med Clin (Barc)

Rev Clin Esp

Rev Clin Esp

Chronic obstructive pulmonary disease: current burden and future projections

Eur Respir J

Prevalence of COPD in Spain: impact of undiagnosed COPD on quality of life and daily life activities

Thorax

Systemic manifestations and comorbidities of COPD

Eur Respir J

Original
Comorbilidades en pacientes hospitalizados por enfermedad pulmonar obstructiva crónica. Análisis comparativo de los estudios ECCO y ESMIComorbidities in patients hospitalized due to chronic obstructive pulmonary disease. A comparative analysis of the ECCO and ESMI studies