Depression predicts emergency care use in people with chronic obstructive pulmonary disease: a large cohort study in primary care

Figures & data

Figure 1 Flow of study participants.

Table 1 Characteristics of the 355 study participants: significance of effect on attendance at ED and nonelective admissions in the follow-up year

Data supplied by practices	Included participants (N=355) N (%)	Attended ED			Nonelective admission
		No (N=265) N (%)	Yes (N=90) N (%)	Significance^a	No (N=263) N (%)	Yes (N=92) N (%)	Significance^a
Age group:  <50  50–59  60–69  70–79  ≥80	19 (5.4) 59 (16.6) 127 (35.8) 95 (26.8) 55 (15.5)	15 (5.7) 53 (20.0) 102 (38.5) 62 (23.4) 33 (12.5)	4 (4.4) 6 (6.7) 25 (27.8) 33 (36.7) 22 (24.4)	<0.001	15 (5.7) 53 (20.2) 101 (38.4) 62 (23.6) 32 (12.2)	4 (4.3) 6 (6.5) 26 (28.3) 33 (35.9) 23 (25.0)	<0.001
Female	168 (47.3)	127 (47.9)	41 (45.6)	0.72	126 (47.9)	42 (45.7)	0.72
QOF diagnoses:
Mental health	68 (19.2)	53 (20.0)	15 (16.7)	0.54	53 (20.2)	15 (16.3)	0.45
Depression	27 (7.6)	21 (7.9)	6 (6.7)	0.82	21 (8.0)	6 (6.5)	0.82
CHD	55 (15.5)	33 (12.5)	22 (24.4)	0.011	32 (12.2)	23 (25.0)	0.007
Heart failure	20 (5.6)	10 (3.8)	10 (11.1)	0.015	9 (3.4)	11 (12.0)	0.006
Stroke	17 (4.8)	10 (3.8)	7 (7.8)	0.15	10 (3.8)	7 (7.6)	0.16
Hypertension	178 (50.1)	123 (46.4)	55 (61.1)	0.020	122 (46.%)	56 (60.9)	0.021
Diabetes mellitus	68 (19.2)	51 (19.2)	17 (18.9)	1.0	50 (19.0)	18 (19.6)	0.88
Epilepsy	6 (1.7)	3 (1.1)	3 (3.3)	0.17	3 (1.1)	3 (3.3)	0.18
Hypothyroid	24 (6.8)	16 (6.0)	8 (8.9)	0.34	42 (6.0)	22 (8.7)	0.23
Cancer	49 (13.8)	33 (12.5)	16 (17.8)	0.22	33 (12.5)	16 (17.4)	0.29
Asthma	31 (8.7)	20 (7.5)	11 (12.2)	0.20	20 (7.6)	11 (12.0)	0.20
Dementia	4 (1.1)	2 (0.8)	2 (2.2)	0.27	2 (0.8)	2 (2.2)	0.28
Kidney disease	38 (10.7)	25 (9.4)	13 (14.4)	0.24	25 (9.5)	13 (14.1)	0.24
Atrial fibrillation	21 (5.9)	13 (4.9)	8 (8.9)	0.20	13 (4.9)	8 (8.7)	0.20
Number of QOF conditions out of the 12 above:^b  0  1  2  3 or more	94 (26.5) 120 (33.8) 74 (20.8) 67 (18.9)	79 (29.8) 93 (35.1) 53 (20.0) 40 (15.1)	15 (16.7) 27 (30.0) 21 (23.3) 27 (30.0)	<0.001	79 (30.0) 93 (35.4) 52 (19.8) 39 (14.8)	15 (16.3) 27 (29.3) 22 (23.9) 28 (30.4)	<0.001
Severity of COPD^c:  Mild  Moderate  Severe  Very severe	78 (22.8) 186 (54.4) 76 (22.2) 2 (0.6)	61 (23.7) 145 (56.4) 49 (19.1) 2 (0.8)	17 (20.0) 41 (48.2) 27 (31.8) 0 (0)	0.084	60 (23.5) 145 (56.9) 49 (19.2) 1 (0.4)	18 (20.7) 41 (47.1) 27 (31.0) 1 (1.1)	0.059
Severity of COPD unknown	13 (3.7)	8 (3.0)	5 (5.6)	0.33	8 (3.0)	5 (5.4)	0.33
Attended ED in prebaseline year	104 (29.3)	64 (24.2)	40 (44.4)	<0.001	64 (24.3)	40 (43.5)	0.001
Nonelective admission in prebaseline year	59 (16.6)	33 (12.5)	26 (28.9)	0.001	33 (12.5)	26 (28.3)	0.001

Notes: ^aComparison used chi-squared test for linear trend across age, severity and number of QOF groups, and Fisher’s exact test for dichotomous variables. ^bPhysical health conditions only, mental health and depression were excluded from total QOF conditions. ^cMissing severity of COPD for 13 patients (5 who attended ED in the follow-up year and 8 who did not, 5 who had a nonelective admission in the follow-up year and 8 who did not).

Abbreviations: CHD, coronary heart disease; COPD, chronic obstructive pulmonary disease; QOF, Quality and Outcomes Framework; ED, emergency department.

Table 2 Characteristics of the study participants on baseline questionnaires: significance of effect on attendance at ED and nonelective admissions in the follow-up year

Baseline questionnaire data (N=355)	Whole group (N=355) N (%)	Attended ED			Nonelective admission
		No (N=265) N (%)	Yes (N=90) N (%)	Significance^a	No (N=263) N (%)	Yes (N=92) N (%)	Significance^a
White ethnic group		253 (95.5)	84 (93.3)	0.41	251 (95.4)	86 (93.5)	0.42
Marital status^b: Single Married or cohabiting Widowed, separated or divorced	56 (16.0) 169 (48.4) 124 (35.5)	45 (17.1) 128 (48.7) 90 (34.2)	11 (12.8) 41 (47.7) 34 (39.5)	0.53	44 (16.9) 128 (49.0) 89 (34.1)	12 (13.6) 41 (46.6) 35 (39.8)	0.58
Living alone	126 (35.9)	90 (34.4)	36 (40.4)	0.31	88 (33.8)	38 (41.8)	0.20
Poor education^c	266 (74.9)	190 (71.7)	76 (84.4)	0.017	188 (71.5)	78 (84.8)	0.012
Not working due to ill health	72 (20.3)	56 (21.1)	16 (17.8)	0.55	56 (21.3)	16 (17.4)	0.46
Unemployed but seeking work	7 (2.0)	7 (2.6)	0	0.20	7 (2.7)	0	0.20
HADS anxiety 8 or more^d	181 (51.7)	131 (49.8)	50 (57.5)	0.22	130 (49.8)	51 (57.3)	0.27
HADS depression 8 or more^d	173 (49.4)	118 (44.9)	55 (63.2)	0.004	118 (45.2)	55 (61.8)	0.007
HADS total 17 or more^d	162 (46.3)	116 (44.1)	46 (52.9)	0.17	116 (44.4)	46 (51.7)	0.27

Notes: Comparison between 2 groups used the chi-squared test, or Fisher’s exact test, as appropriate. ^bMissing data for 6 participants. ^cPoor education defined by not having any GCSE’s, O levels or higher. ^dMissing data for 5 participants.

Abbreviations: ED, emergency department; HADS, Hospital Anxiety and Depression Scale.

Table 3 ORs of potential risk factors for ED attendance and emergency hospital admissions in the follow-up year (N=350)

Potential risk factor	DV=ED			DV=emergency admission
	OR	95% CI	Significance	OR	95% CI	Significance
Age per 10 years	1.59	1.11–2.28	0.011	1.51	1.06–2.15	0.023
Number of physical QOF diagnoses	1.21	0.99–1.49	0.063	1.23	1.01–1.51	0.043
Severity of COPD	1.54	1.03–2.30	0.036	1.53	1.03–2.28	0.037
Used UC in the prebaseline year^a	2.37	1.36–4.14	0.002	2.05	1.08–3.89	0.028
HADS depression score ≥8	2.78	1.55–4.99	0.001	2.63	1.48–4.66	0.001

Notes: ^aUC, unscheduled care, ED attendance in prebaseline year for ED attendance in prospective year, and emergency admissions in prebaseline year for emergency admissions in the follow-up year.

Abbreviations: COPD, chronic obstructive pulmonary disease; ED, emergency department; DV, dependent variable; QOF, Quality and Outcomes Framework.

Table 4 ORs for HADS depression in four quartile groups by ED visits and emergency inpatient admissions in the follow-up year (N=350)

HADS depression score at baseline	ED			Emergency admission
	OR	95% CI	Significance	OR	95% CI	Significance
0–3	Reference group			Reference group
4–7	2.40	1.02–5.61	0.044	2.84	1.23–6.58	0.015
8–11	4.56	1.96–10.6	<0.001	4.80	2.07–11.1	<0.001
12 or more	4.65	1.97–11.0	<0.001	4.82	2.05–11.3	<0.001

Notes: HADS depression scores in four quartiles: ORs adjusted for age, sex, poor education, number of QOF physical diagnoses, severity of COPD and either ED or emergency admission in the previous year

Abbreviations: COPD, chronic obstructive pulmonary disease; HADS, Hospital Anxiety and Depression Scale; ED, emergency department; QOF, Quality and Outcomes Framework.

Data availability

Data may be available on request from the authors.