Background
Methods
Study design
Collected data
Statistical analysis
Results
Population and treatments characteristics
N = 2494 | Mean ± SD or% |
---|---|
Age (years) | 67.0 ± 10.6 |
Male (%) | 78% |
Body mass index (kg/m2) | 25.84 ± 5.17 |
Smokers / ex-smokers | 25.6% / 62.4% |
Chronic bronchitis without airflow obstruction / COPD | 23.7% / 76.3% |
(GOLD stage): 1 / 2 / 3 / 4 | 2.9% / 29.7% / 26.1% / 17.6% / |
FEV1 (L/sec) | 53.1 ± 19.6 |
Duration of chronic bronchitis / COPD (years) | 8.0 ± 7.8 |
Chronic cough / sputum production | 70.5% / 72.2% |
Chronic cough with sputum production by GOLD stage in COPD patients: GOLD 1/2/3/4 | 62.0% / 71.9% / 72.4% / 76.4% |
Modified Medical Research Council dyspnea grade: 1 / 2 / 3 / 4 / 5 | 14.2% / 30.3% / 30.5% / 16.2% / 6.1% |
At least one exacerbation during the last 12 months | 86.3% |
Number of exacerbations per year | |
-Mild / moderate (oral corticosteroids or antibiotics) | 1.4 ± 2.3 / 1.6 ± 1.7 |
-Severe (hospitalization) / very severe (intensive care unit) | 0.3 ± 0.8 / 0.0 ± 0.2 |
Comorbidities | |
-CHD / CHF / RVF | 14.9% / 6.5% / 7.2% |
-Asthma / bronchiectasis / sleep apnea syndrome | 11.9% / 6.3% / 8.6% |
-Depression | 7.9% |
Investigations and follow-up during the past 12 months | |
-Arterial blood gases / EKG | 70.0% / 68.8% |
-CT-scan / echocardiography | 61.6% / 50.6% |
-Sleep oximetry / polysomnography | 23.2% / 15.4% |
-6MWT | 27.9% |
Visits to respiratory physicians / GPs | 2.6 ± 1.7 / 6.7 ± 4.1 |
Treatments | |
-ICS / Fixed ICS + LABA combinations | 22.8% / 51.5% |
-SABA / SABA + SAMA | 34.9% / 29.9% |
-LABA / LAMA | 26.6% / 17.0% |
-Theophylline / oral corticosteroids | 8.3% / 4.5% |
-LTOT / LTNIV | 16.6% / 4.8% |
-Influenza / pneumococcal vaccines | 81.2% / 58.2% |
-Rehabilitation during the last 2 years | 26.9% |
Definition of clinical subtypes by MCA, clustering and their combination
Clinical subtypes | Description, frequency and associated treatment type |
---|---|
1 : Exposed but not severely impaired patients | Exposed to tobacco smoke or occupational smokes, toxic gaz or dust. No severe airflow obstruction (VEMS > 60%). MRC grade 0 (maximum MRC grade = 2). |
9.62%* of patients met the first three conditions. | |
Patients of this clinical subtype are underrepresented in all treatment subgroups and particularly respiratory support (treatment group 4: OR = 0.198). All treatment types are less prescribed to this clinical subtypes and particularly respiratory support (treatment subgroup 4: OR = 0.255). | |
2 : Overweight smokers with high blood pressure and other comorbidities | Sleep apnea. Men. Robust stature (weight >80 kg). Current smokers. Underwent polysomnography. High blood pressure. Large variety of other comorbidities. Rather mild or moderate MRC grade. |
6.50%* of patients met the first three conditions. | |
Patients of this clinical subtype are overrepresented among prescriptions of respiratory support (treatment subgroup 4: OR = 3.625) and underrepresented among prescriptions of vaccines (treatment subgroup 6: OR = 0.581). | |
3 : Severe airflow obstruction | Severe dyspnea (MRC grade 4 or 5). Low FEV1 (< 50%) and FVC. Chronic right ventricular failure. Emphysema. Many investigations performed or prescribed including lung CT-scan, bronchoscopy, DLCO, 6-min walking test, sleep oxymetry, arterial blood gases, exercise testing, echocardiography, EKG, lung scintigraphy. |
16.06%* of patients met the first two conditions. | |
Patients of this clinical subtype are overrepresented in all treatment subgroups and particularly respiratory support (treatment subgroup 4: OR = 6.214). All treatment subgroups are more prescribed to this clinical subtype, and particularly respiratory support (treatment subgroup 4: OR = 7.381). | |
4 : Women | Women. Small stature (< 66 kg, < 165 cm). Small respiratory capacity (FEV1 < 1 l, FVC < 2 l). 60 years old or more. MRC grade can be severe. Often living alone. Possibly depressive. Living in town. Associated asthma is possible. Were prescribed reversibility testing. |
12.70% *of patients met the first three conditions. | |
Patients of this clinical subtype are not significantly overrepresented or underrepresented in any treatment subgroup and no treatment subgroup is significantly more (or less) prescribed to this clinical subtype (no special treatment for women). | |
5 : Patients with symptoms of chronic bronchitis | Chronic cough and sputum production, chronic bronchitis. Fibrous or cavity sequelae and bronchiectasis in some patients. Not strongly related to MRC grade but rather moderate. |
67.07%* of patients met the first three conditions. | |
Patients of this clinical subtype are not significantly overrepresented or underrepresented in any treatment subgroup except for vaccines (type 6: OR = 2.210) and no treatment subgroup except for type 6 is significantly more (or less) prescribed to this clinical subtype.. | |
6 : Elderly patients with cardiovascular comorbidity | Age > 75 years. Heart diseases: heart failure, ischemic heart disease or other cardiovascular diseases.Not strongly related to MRC grade but rather moderate. High blood pressure. Possible peripheral artery disease and cancer. |
11.06%* of patients met the first and at least one of the 3 other conditions. | |
Patients of this clinical subtype are significantly underrepresented in nebulised treatment (treatment subgroup 1: OR = 0.686) and overrepresented in fixed combinations (treatment subgroup 2: OR = 1.335) and vaccines (treatment subgroup 6: OR = 1.335). Nebulised treatments are significantly less prescribed to this clinical subtype. Fixed combinations and vaccines are significantly more prescribed to these patients. |
Treatment subgroups defined by MCA, clustering and their combination
Treatment subgroups | Description, frequency |
---|---|
1: Nebulised treatments | Nebulised anticholinergics and/or beta2 agonists. Less frequently, nebulised corticosteroids. |
One of the first two treatments was prescribed to 45.55% of patients. | |
2: Fixed combinations | Combinations of long acting beta 2 agonist and corticosteroids. |
These combinations were prescribed to 51.44% of patients. | |
3 : LABA and inhaled corticosteroids prescribed separately | LABA and inhaled corticosteroids, co-prescribed in 91.2% of patients who receive one and/or the other outside of a fixed combination. |
Such “separate associations” were prescribed to 16.03% of patients. | |
4: Non-invasive ventilation and oxygen therapy | Ventilation or oxygen therapy. Respiratory support may be prescribed with respiratory rehabilitation. |
One of the first two therapies was prescribed to 18.71% of patients. | |
5: Fixed combinations of short-acting anticholinergic and β2 agonist | These treatments are not prescribed in patients who receive long acting anticholinergics. Prescription of a fixed combination of LABA and ICS is possible and independent (neither association nor exclusion). |
These fixed combinations were prescribed to 29.85% of patients. | |
6: Flu and pneumococcal vaccines | Flu or pneumococcal vaccines and antibiotics, sometimes associated with chest physiotherapy. |
At least one of the two first vaccines and antibiotics were prescribed to 39.83% of patients. |
Relationship between clinical subtypes and treatment subgroups
Odds ratio |
Trt type 1
|
Trt type 2
|
Trt type 3
|
Trt type 40
|
Trt type 5
|
Trt type 6
|
---|---|---|---|---|---|---|
Nebulised treatments | Fixed combinations | LABA and inhaled corticosteroids prescribed separately | Non-invasive ventilation and oxygen therapy | Fixed combinations of short acting anticholinergic and β2 agonist | Flu and pneumococcal vaccines | |
Clinical type 1 | ||||||
Exposed but not severely impaired patients |
0.611
3
|
0.713
1
|
0.581
1
|
0.198
4
|
0.592
2
|
0.575
3
|
0.636
2
|
0.800
0
|
0.686
1
|
0.255
3
|
0.637
2
|
0.500
4
| |
Clinical type 2 | ||||||
Overweight smokers with comorbidities | 0.7810
| 0.9070
| 0.8910
|
3.625
4
| 1.0600
|
0.581
2
|
0.877
0
|
0.939
0
|
1.004
0
|
4.396
4
|
1.221
0
|
0.762
0
| |
Clinical type 3 | ||||||
Severe airflow obstruction |
1.636
3
|
1.605
3
|
1.580
1
|
6.214
4
|
1.382
1
|
1.606
3
|
1.683
4
|
1.455
3
|
1.207
0
|
7.381
4
|
1.381
2
|
2.095
4
| |
Clinical type 4 | ||||||
Women | 1.1420
| 0.9520
| 1.2930
| 0.8210
| 1.2500
| 1.1050
|
1.097
0
|
0.868
0
|
1.274
0
|
1.101
0
|
1.254
0
|
1.194
0
| |
Clinical type 5 | ||||||
Symptoms of chronic bronchitis | 1.1160
| 0.9860
| 0.8680
| 1.1170
| 1.0950
|
2.210
4
|
1.161
0
|
1.083
0
|
0.912
0
|
1.243
0
|
1.107
0
|
2.221
4
| |
Clinical type 6 | ||||||
Elderly patients with cardiovascular comorbidity |
0.686
2
|
1.335
1
| 1.0220
| 1.3080
| 0.9540
|
1.441
2
|
0.733
1
|
1.323
1
|
0.899
0
|
1.200
0
|
1.087
0
|
1.351
1
|
Overall relationships between patients’ characteristics and pharmacological and non-pharmacological treatments
Family | Selected variables | Adjusted R2
| P value |
---|---|---|---|
Socio-demographics | stature, age, lifestyle (living alone,…), | 0.0047 | 0.001 |
History of COPD and comorbidities | history of right ventricular failure, emphysema, sleep apnea, asthma, dyspnea, chronic sputum production, ischemic heart disease. | 0.01998 | 0.001 |
Symptoms the days of visit | dyspnea (MRC), chronic bronchitis | 0.02515 | 0.001 |
Lung function | FEV1, FEV1%, FVC, | 0.02120 | 0.001 |
Exacerbations and smoking status | number of exacerbations, current smoking, current occupational exposure to dust or smoke | 0.00626 | 0.00494 |
Investigations (d. stands for done and p. for prescribed) | sleep oxymetry d., walking test d., arterial blood gases d., scintigraphy d., polysomnography d., ECG d., VO2max d., VO2max p., 6MWT p., DLCO p., scintigraphy p., EKG p. | 0.03927 | 0.001 |
Family | Selected variables | Adjusted R2
| P value |
---|---|---|---|
Socio-demographics | age, weight, town, gender | 0.02517 | 0.001 |
History of COPD and comorbidities | emphysema, chronic sputum production, dyspnea, history of right ventricular failure, bronchiectasis, ischemic heart disease, asthma, cough, depression, heart failure. | 0.04009 | 0.001 |
Symptoms the days of visit | dyspnea (MRC), chronic bronchitis | 0.05125 | 0.001 |
Lung function | FEV1, FEV1%, reversibility testing, FVC | 0.03641 | 0.001 |
Exacerbations and smoking status | number of exacerbations, current smoking, current occupational exposure to dust or smoke | 0.04385 | 0.001 |
Investigations (d. stands for done and p. for prescribed) | 6MWT d., CT-scan d., echocardiography d., arterial blood gases d., scintigraphy. d., nocturnal oxymetry d., 6MWT p., arterial blood gases p., EKG d., DLCO p., fiberoptic bronchoscopy d., DLCO d., EKG p. | 0.07245 | 0.001 |