Trends in Outcomes, Financial Burden, and Mortality for Acute Exacerbation of Chronic Obstructive Pulmonary Disease (COPD) in the United States from 2002 to 2010

Figures & data

Table 1. National estimates of acute COPD exacerbation-related hospitalizations, 2002–2010.

	2002	2003	2004	2005	2006	2007	2008	2009	2010	Slope	p Value
Overall COPD-related hospitalization
Total hospitalization	1,002,902	1,075,400	974,818	964,497	934,499	957,666	1,086,123	1,113,566	1,075,575	10,349	0.257
% of overall adult hospitalization	3.31	3.51	3.15	3.11	2.95	3.04	3.39	3.52	3.43	0.020	0.608
Age-adjusted % of overall adult hospitalization^*	2.13	2.24	2.00	1.95	1.86	1.94	2.10	2.22	2.15	0.003	0.854
Hospitalization rate per 10,000 adult population	47	50	44	43	42	42	47	48	46	−0.083	0.836
Primary diagnosis
Total hospitalization	509,751	525,538	448,508	429,337	407,244	403,206	493,424	510,324	498,442	−453	0.947
% of overall adult hospitalization	1.68	1.71	1.45	1.39	1.29	1.28	1.54	1.61	1.59	−0.01	0.665
Age-adjusted % of overall adult hospitalization^*	1.13	1.14	0.96	0.91	0.85	0.85	0.99	1.06	1.04	−0.01	0.516
Hospitalization rate per 10,000 adult population	24	24	20	19	18	18	21	22	21	−0.28	0.370
Secondary diagnosis
Total hospitalization	493,151	549,862	526,310	535,160	527,255	554,460	592,699	603,242	577,133	10802	0.005
% of overall adult hospitalization	1.63	1.79	1.70	1.73	1.67	1.76	1.85	1.91	1.84	0.026	0.017
Age-adjusted % of overall adult hospitalization^*	1.00	1.09	1.04	1.04	1.01	1.09	1.11	1.16	1.12	0.015	0.021
Hospitalization rate per 10,000 adult population	23	25	24	24	23	24	26	26	25	0.250	0.084
Overall adult hospitalization for all causes in US
All adult hospitalizations in the USA	30,268,725	30,676,256	30,966,846	30,978,228	31,628,376	31,551,163	32,060,332	31,647,642	31,318,051

^*age-adjusted rates were calculated using direct standardization with 2002 as reference population.

Table 2. Baseline characteristics of hospitalizations from COPD, 2002–2010.

	2002	2003	2004	2005	2006	2007	2008	2009	2010
Age in years (mean ± SD)	70.3 ± 0.2	70.3 ± 0.2	70.4 ± 0.1	70.6 ± 0.1	70.3 ± 0.2	70.2 ± 0.2	70.5 ± 0.2	69.7 ± 0.2	69.9 ± 0.2
Race (%)
White	83.2	81.4	83.4	85.6	82.4	82.1	83.4	81.7	81
Black	9.1	8.5	8.7	6.9	9.0	9.9	8.3	9.0	11
Hispanic	4.9	6.6	4.6	4.8	5.3	4.6	4.1	4.9	5
Others	2.8	3.5	3.3	2.7	3.2	3.4	4.2	4.4	3
Gender (female, %)	53	53	53	53	53	53	53	53	53
Household income (%)^*
First quartile	36.6	33.9	34.8	33.4	34.2	35.9	33.3	34.5	35.4
Second quartile	27.4	28.5	29.2	28.2	27.7	28.1	31.0	29.5	27.9
Third quartile	28.0	22.7	20.3	22.3	22.2	21.3	20.7	21.6	21.8
Fourth quartile	8.0	14.9	15.7	15.9	15.9	14.7	15.0	14.2	14.9

^*2003–2010: Median household income (1) $1– $38,999; (2) $39,000–$47,999; (3) $48,000–62,999; and (4) $63,000 or more.

2002: Median household income (1) $1–$24,999, (2) $25,000–$34,999, (3) $35,000–$44,999, and (4) $45,000 or more.

Table 3. Admission source, type, and region of hospitals of hospitalized COPD patients in the United States from 2002 to 2010.

	2002	2003	2004	2005	2006	2007	2008	2009	2010
Admission source (%)
Emergency department	74.0	73.3	72.9	72.0	73.2	74.6	76.5	72.5	77.2
Another hospital	2.0	2.0	2.1	2.5	2.6	2.5	2.2	3.6	4.1
Other facility including long-term care	1.6	1.5	1.7	1.6	1.6	1.6	1.7	2.8	3.1
Others	22.4	23.2	23.3	23.9	22.6	21.2	19.6	21.0	15.6
Weekend admission (%)	23.5	23.6	23.5	23.4	23.5	23.7	24.0	23.8	24.2
Hospital location (%)
Rural	25.2	27.0	24.7	23.7	23.7	22.1	21.5	21.7	21.7
Urban	74.8	78.0	75.3	76.3	76.3	77.9	78.5	78.3	78.3
Teaching status of the hospital (%)
Nonteaching	71.8	72.6	73.2	74.4	66.8	68.3	68.2	69.1	68.1
Teaching	28.1	27.4	26.7	25.6	33.1	31.7	31.8	30.9	31.9
Hospital bed size (%)
Small	14.5	14.8	15.9	16.2	17.8	16.5	17.1	16.3	16.6
Medium	28.2	28.8	27.1	27.0	26.9	26.9	24.5	24.4	25.4
Large	57.3	56.4	57.0	56.8	55.3	56.6	58.4	59.3	58.0
Region of admitting hospital (%)
Northeast	19.1	18.8	17.7	18.2	18.3	18.1	17.0	17.9	17.9
Midwest	22.9	22.7	24.1	23.8	24.1	25.4	26.1	23.4	25.3
South	43.9	44.8	45.0	44.5	43.7	43.1	42.7	44.3	42.5
West	14.1	13.7	13.2	13.5	13.9	13.4	14.2	14.4	14.3

Table 4. Length of hospital stay, clinical outcomes, payer, and hospital charges of hospitalized COPD patients in the United States from 2002 to 2010.

	2002	2003	2004	2005	2006	2007	2008	2009	2010	Slope	p value
Length of stay (days, mean ± SD)
COPD-related	6.4 ± 0.1	6.3 ± 0.1	6.3 ± 0.1	6.3 ± 0.1	6.2 ± 0.1	6.2 ± 0.1	6.2 ± 0.1	6.1 ± 0.1	6.0 ± 0.1	−0.042	<0.001
Primary diagnosis	5.1 ± 0.1	5.0 ± 0.1	4.9 ± 0.1	4.9 ± 0.1	4.8 ± 0.1	4.6 ± 0.1	4.7 ± 0.1	4.6 ± 0.1	4.4 ± 0.1	−0.078	<0.001
Secondary diagnosis	7.7 ± 0.1	7.5 ± 0.1	7.5 ± 0.1	7.5 ± 0.1	7.3 ± 0.1	7.3 ± 0.1	7.5 ± 0.1	7.4 ± 0.2	7.3 ± 0.1	−0.035	0.029
Patient Disposition (%)
Routine discharge tohome	61.4	61.3	56.1	55.8	55.2	54.3	53.7	54.3	52.3
Short-term hospital	2.4	2.3	2.4	2.5	2.4	2.5	2.5	2.6	2.4
Skilled nursing facility	18.4	18.2	20.0	20.3	20.3	21.1	20.9	20.7	21.3
Home healthcare	12.2	12.7	15.8	15.7	16.4	16.5	17.2	17.0	18.7
Against medical advice	0.8	0.8	0.9	0.9	1.1	1.1	1.1	1.2	1.3
Other (alive but destination unknown, died, etc.)	4.8	4.7	4.6	4.7	4.6	4.3	4.4	4.1	4.0
In-hospital mortality (%)
COPD-related	4.8	4.5	4.5	4.6	4.5	4.3	4.3	4.0	3.9	−0.096	<0.001
Primary diagnosis	2.4	2.2	2.1	2.1	2.0	1.8	1.8	1.5	1.4	−0.117	<0.001
Secondary diagnosis	7.2	6.8	6.6	6.6	6.4	6.1	6.4	6.1	6.0	−0.130	<0.001
Primary expected payer (%)
Medicare	74.3	75.0	75.0	75.8	75.3	74.0	73.4	72.6	73.0
Medicaid	8.2	8.4	8.3	8.2	8.5	8.3	8.2	9.3	9.8
Private insurance (including HMO)	13.5	12.6	12.3	11.9	11.7	12.9	13.6	12.9	12.4
Self-pay	1.9	1.9	2.2	2.2	2.3	2.5	2.4	2.8	2.6
Others	2.1	2.1	2.2	1.9	2.2	2.2	2.4	2.4	2.2
Total charges ($, mean ± SD)
COPD-related	22,187 ± 82.4	23,715 ± 83.3	25,551 ± 89.6	27,376 ± 93.7	29,122 ± 96.4	31,458 ± 105	34,704 ± 107	36,603 ± 117	38,455 ± 117	2102	<0.001
Primary diagnosis	15,218 ± 72.1	16,247 ± 76.9	17,219 ± 83.1	18,180 ± 89.1	19,181 ± 87.7	20,665 ± 105.3	22,540 ± 93.1	23,907 ± 106.7	24291 ± 98.8	1206	<0.001
Secondary diagnosis	29,378 ± 146	30,909 ± 142	32,703 ± 147	34,821 ± 149	36,982 ± 153	39,389 ± 162	44,907 ± 176	47,422 ± 191	50,659 ± 194	2727	<0.001

Table 5. Differences in mortality, length of stay, and total charges between age groups <40 years and 40 years or more for 2002 and 2010.

	2002			2010
	Age < 40 years^+	Age ≥ 40 years	p value	Age < 40 years^@	Age ≥ 40 years	p value
Mortality, % (SE)
Overall	0.9 (0.2)	4.8 (0.1)	<0.001	0.8 (0.2)	3.9 (0.1)	<0.001
Primary diagnosis	0.4 (0.1)	2.5 (0.1)	<0.001	0.2 (0.1)	1.4 (0.1)	<0.001
Secondary diagnosis	1.5 (0.4)	7.3 (0.1)	<0.001	1.4 (0.4)	6.0 (0.1)	<0.001
Length of stay, days (SE)
Overall	4.6 (0.1)	6.4 (0.1)	<0.001	4.6 (0.2)	6.0 (0.1)	<0.001
Primary diagnosis	3.7 (0.1)	5.1 (0.1)	<0.001	3.1 (0.1)	4.5 (0.1)	<0.001
Secondary diagnosis	5.7 (0.2)	7.7 (0.1)	<0.001	5.9 (0.3)	7.3 (0.1)	<0.001
Total charges, $ (SE)
Overall	15,237 (511.2)	22,261 (83)	<0.001	30,022(1428)	38,506 (118)	<0.001
Primary diagnosis	10,712 (401)	15,273 (73)	<0.001	17,804 (890)	24,332 (99)	<0.001
Secondary diagnosis	21,326 (1040)	29,453 (147)	<0.001	40,999 (2520)	50,716 (195)	<0.001

SE–standard error

⁺accounted for 1.06% of overall COPD hospitalizations.

^@accounted for 0.60% of overall COPD hospitalizations.

Table 6. Predictors of inpatient mortality among patient with acute COPD exacerbation-related hospitalization for 2010.

	Univariate analysis		Multivariate analysis
	OR (95% CI)	p value	OR (95% CI)	p value
Age	1.04 (1.03–1.05)	<0.001	1.05 (1.04–1.06)	<0.001
Gender
Female	1.0 (ref)
Male	1.24 (1.18–1.29)	<0.001	1.14 (1.09–1.20)	<0.001
Race
Caucasian	1.0 (ref)
African American	0.75 (0.69–0.81)	<0.001	0.77 (0.70–0.85)	<0.001
Hispanic	0.96 (0.86–1.07)	0.503	0.85 (0.76–0.96)	0.010
Asian or pacific islander	1.78 (1.53–2.09)	<0.001	1.07 (0.90–1.28)	0.435
Native American	0.78 (0.60–1.07)	0.131	0.92 (0.66–1.28)	0.617
Other	1.19 (1.02–1.40)	0.027	1.14 (0.96–1.35)	0.142
Length of stay	1.05 (1.04–1.06)	<0.001	1.009 (1.007–1.012)	<0.001
Hospital bed size
Small	1.0 (ref)
Medium	1.00 (0.94–1.07)	0.948	0.91 (0.84–0.98)	0.011
Large	1.06 (1.01–1.13)	0.042	0.94 (0.88–1.00)	0.054
Hospital location
Rural	1.0 (ref)
Urban	1.25 (1.19–1.33)	<0.001	0.96 (0.89–1.02)	0.174
Hospital's teaching status
Nonteaching	1.0 (ref)
Teaching	1.13 (1.08–1.18)	<0.001	1.08 (1.03–1.14)	0.004
Other clinical diagnosis^*
Septicemia	7.35 (7.00–7.72)	<0.001	3.94 (3.71–4.19)	<0.001
Ventilator-dependent respiratory failure	10.53 (10.04–11.04)	<0.001	8.28 (7.80–8.79)	<0.001
Lung cancer	3.27 (3.05–3.50)	<0.001	3.72 (3.43–4.04)	<0.001
Pancreatic cancer	2.32 (1.31–4.09)	0.004	2.48 (1.32–4.66)	0.005
Esophageal cancer	3.32 (2.21–5.01)	<0.001	3.28 (2.03–5.31)	<0.001
Pulmonary fibrosis	2.41 (161–3.61)	<0.001	2.75 (1.73–4.36)	<0.001
Atrial fibrillation/flutter	2.06 (1.97–2.15)	<0.001	1.36 (1.29–1.44)	<0.001
Congestive heart failure	1.65 (1.58–1.72)	<0.001	1.24 (1.18–1.31)	<0.001
Coronary artery disease	1.20 (1.15–1.25)	<0.001	0.96 (0.92–1.02)	0.169
Gastric/duodenal ulcers	1.79 (1.48–2.16)	<0.001	1.09 (0.87–1.36)	0.442
Liver cirrhosis	1.33 (1.15–1.54)	<0.001	1.57 (1.32–1.86)	<0.001
Diabetes with neuropathy	0.71 (0.60–0.84)	<0.001	0.76 (0.62–0.92)	0.005
Anxiety	0.69 (0.64–0.75)	<0.001	0.95 (0.87–1.05)	0.321

^*compared to individuals without this diagnosis.

CI–confidence interval; OR – odds ratio.

Figure 1. COPD-related hospitalizations over the years. (A) Number of hospitalizations per year (B) Hospitalization rate per 10,000 US population.

Figure 2. Additional cost of hospitalization over the years with 2002 as reference (charges adjusted for medical care inflation).

Figure 3. Trends in inpatient mortality.

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