Title of study: Emergency Department Visits for Acute ...



<This study has been published in Annals of American Thoracic Society>Title of Study: The association of obesity with acute severity of chronic obstructive pulmonary disease exacerbationAuthor: Tadahiro GotoCo-authors (role): NAME (Analysis), NAME (Data management), NAME (supervision), NAME (supervision)Aim: The study objective is:To investigate the association between obesity and severity of acute exacerbation of chronic obstructive pulmonary disease (AECOPD).Hypothesis 1: Obesity is associated with a higher in-hospital mortality, rate of mechanical ventilation use, and longer hospital length-of-stay (LOS).Background (public health burden, what’s known, what’s unknown/knowledge gaps): COPD and obesity are important public health problems. Obesity is prevalent among individuals with COPD, corresponding to 35% of patients with COPD. ADDIN EN.CITE <EndNote><Cite><Author>Ogden</Author><Year>2014</Year><RecNum>87</RecNum><DisplayText><style face="superscript">1</style></DisplayText><record><rec-number>87</rec-number><foreign-keys><key app="EN" db-id="5f5rxrer2z5xeqepzscvpszpx2dx9xsppsve" timestamp="1483848918">87</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Ogden, C. L.</author><author>Carroll, M. D.</author><author>Kit, B. K.</author><author>Flegal, K. M.</author></authors></contributors><auth-address>National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, Maryland.&#xD;National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, Maryland2United States Public Health Service, Rockville, Maryland.</auth-address><titles><title>Prevalence of childhood and adult obesity in the United States, 2011-2012</title><secondary-title>JAMA</secondary-title></titles><periodical><full-title>JAMA</full-title></periodical><pages>806-14</pages><volume>311</volume><number>8</number><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Body Mass Index</keyword><keyword>Body Weight</keyword><keyword>Child</keyword><keyword>Child, Preschool</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Infant</keyword><keyword>Infant, Newborn</keyword><keyword>Male</keyword><keyword>Nutrition Surveys</keyword><keyword>Obesity/*epidemiology</keyword><keyword>Pediatric Obesity/*epidemiology</keyword><keyword>Prevalence</keyword><keyword>Sex Distribution</keyword><keyword>United States/epidemiology</keyword></keywords><dates><year>2014</year><pub-dates><date>Feb 26</date></pub-dates></dates><isbn>1538-3598 (Electronic)&#xD;0098-7484 (Linking)</isbn><accession-num>24570244</accession-num><urls><related-urls><url> Obesity is thought to be a risk factor of an adverse health consequences in patients with AECOPD, such as general quality of life, reduced 6-min walk distance, increased dyspnea.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MYW1iZXJ0PC9BdXRob3I+PFllYXI+MjAxNjwvWWVhcj48

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ADDIN EN.CITE.DATA 2,3 However, there is a dearth of research that examined the relationship between obesity and acute severity of AECOPD. Major articlesAuthor, yearJournalPMIDDesignPopulationOutcomesMain findingsLimitationsAllison A. Lambert2016Chest27568229Secondary analysis of a prospective observational cohort study (COPDGene) in US, 2008-20113,631 patients with COPD1-year mortalityObesity was associated with a poor general quality of life, reduced 6-min walk, increased dyspnea, and a risk of self-reported severe AECOPD.Self-reporting bias.No investigation on in-hospital mortality and ventilation use.Landbo C, 1999AJRCCM10588597Retrospective cohort study, 1976-19782,132 patients with COPD Mortality in COPD within the study periodLow BMI is an independent risk factor for mortality in subjects with COPD, and that the association is strongest in subjects with severe COPD. Mortality continued to decrease with increasing BMI in severe COPDNo investigation on severity of AECOPDKnowledge gap(s): Whether obesity is associated with acute severity of AECOPD.MethodsStudy design: Retrospective cohort study (or cross-sectional study)Study settings: HCUP-SID from seven states (AR, FL, IA, NE, NY, UT, WA) between 2012 and 2013Study population: Inclusion criteria: Patients aged ≥40 years and hospitalized for AECOPD (defined by ICD-9-CM codes: 491.21, 491.22, 491.8, 491.9, 492.8, 493.20, 493.21, 493.22, and 496), or those with a primary diagnosis of respiratory failure (codes: 518.81, 518.82, 518.84, and 799.1) and a secondary diagnosis of COPD. ADDIN EN.CITE <EndNote><Cite><Year>2014</Year><RecNum>3989</RecNum><DisplayText><style face="superscript">4</style></DisplayText><record><rec-number>3989</rec-number><foreign-keys><key app="EN" db-id="r90e5wvt8r9spdez50t522tpw2w9aadvtdvv">3989</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors></contributors><titles><title>Yale New Haven Health Services Corporation/Center for Outcomes Research &amp; Evaluation. 2014 Measures Updates and Specifications Report Hospital-Level 30-Day Risk-Standardized Readmission Measures</title></titles><volume>2015</volume><number>October 1</number><dates><year>2014</year></dates><urls><related-urls><url> 1</custom2></record></Cite></EndNote>4Exclusion criteria: Patients who left the hospital against medical advice, patients who were transferred to another acute care facility. ADDIN EN.CITE <EndNote><Cite><Year>2014</Year><RecNum>3989</RecNum><DisplayText><style face="superscript">4</style></DisplayText><record><rec-number>3989</rec-number><foreign-keys><key app="EN" db-id="r90e5wvt8r9spdez50t522tpw2w9aadvtdvv">3989</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors></contributors><titles><title>Yale New Haven Health Services Corporation/Center for Outcomes Research &amp; Evaluation. 2014 Measures Updates and Specifications Report Hospital-Level 30-Day Risk-Standardized Readmission Measures</title></titles><volume>2015</volume><number>October 1</number><dates><year>2014</year></dates><urls><related-urls><url> 1</custom2></record></Cite></EndNote>4Important variables: Age, sex, race/ethnicity, primary payer, median household income, patient residence (urban vs. rural), hospital state, and new Elixhauser comorbidity indices.Aim 1Primary exposure(s)Obesity in any diagnosis fields (280.00, 280.02, v85.31-v85.39, v85.41-v85.45)Outcome(s)Primary: In-hospital mortalitySecondary: The use of mechanical ventilation (invasive mechanical ventilation and NIPPV), and hospital LOS.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MaW5kZW5hdWVyPC9BdXRob3I+PFllYXI+MjAxNDwvWWVh

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ADDIN EN.CITE.DATA 5,6ConfoundersAge, sex, race/ethnicity, primary payer, median household income, patient residence (urban vs. rural), comorbidities, and hospital state.Effect modifiers (if any)Sex?Mediators (if any)Statistical analysis: Main analysis: Unadjusted and adjusted logistic regression models with generalized estimating equations (GEE) to account for patient clustering within-hospitals, with normal and overweight individuals as the reference.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MYW1iZXJ0PC9BdXRob3I+PFllYXI+MjAxNjwvWWVhcj48

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ADDIN EN.CITE.DATA 2 For LOS as an outcome measure, negative binomial model with GEE will be used to account for overdispersion.Sensitivity analysis: Stratification by age category (40-64 and ≥65 years) and sex.Potential limitations: (e.g., selection bias, measurement bias, confounders, generalizability)?Lack of BMI information and low sensitivity of obesity (but high specificity): biasing toward the null.?Lack of clinical information, such as medication and lung function.?Generalizability: patients with severe AECOPD only.Timeline:MilestonesPlanned date (month/year)Finalize analytical plan (this 2-pager summary)MM/DD/YYYYPrimary data analysis DoneFinish first draftMM/DD/YYYYSubmit primary manuscript (brief report) to *** journalBy early MM, YYYYFuture plans (brief): References: ADDIN EN.REFLIST 1.Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA. 2014;311(8):806-814.2.Lambert AA, Putcha N, Drummond MB, et al. Obesity is Associated with Increased Morbidity in Moderate to Severe COPD. Chest. 2016.3.O'Donnell DE, Ciavaglia CE, Neder JA. When obesity and chronic obstructive pulmonary disease collide. Physiological and clinical consequences. Ann Am Thorac Soc. 2014;11(4):635-644.4.Yale New Haven Health Services Corporation/Center for Outcomes Research & Evaluation. 2014 Measures Updates and Specifications Report Hospital-Level 30-Day Risk-Standardized Readmission Measures. 2014; . Accessed October 1, 2015.5.Lindenauer PK, Stefan MS, Shieh MS, Pekow PS, Rothberg MB, Hill NS. Outcomes associated with invasive and noninvasive ventilation among patients hospitalized with exacerbations of chronic obstructive pulmonary disease. JAMA Intern Med. 2014;174(12):1982-1993.6.Hasegawa K, Tsugawa Y, Tsai CL, Brown DF, Camargo CA, Jr. Frequent utilization of the emergency department for acute exacerbation of chronic obstructive pulmonary disease. Respir Res. 2014;15:40. ................
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