Comparative study on health care utilization and hospital outcomes of severe acute exacerbation of chronic obstructive pulmonary disease managed by pulmonologists vs internists

Figures & data

Table 1 Characteristics of pulmonologists and internists involved in this study

Variables	Pulmonologist	Internists	P-value
	N=8	N=25
Age (years)	40.1±6.8	28.4±2.0	<0.001
Male sex	7 (87.5)	12 (48.0)	0.049
Experience in internal medicine (years)	12.6±7.2	3.6±1.4	<0.001

Notes: Results are expressed as mean ± standard deviation or n (%). Bold values indicate P-value reached statistical significance (<0.05).

Table 2 Characteristics of COPD patients in Group A and Group B

Variables	Pulmonologist (Group A)	Internists (Group B)	P-value
	N=137	N=71
Age (years)	72.9±8.6	70.6±8.8	0.307
Male sex	77 (56.2)	44 (62.0)	0.424
Body mass index (kg/m^2)	20.2±3.7	21.9±5.2	0.016
Current smoker	10 (7.3)	8 (11.3)	0.523
Duration of symptom (years)	8.8±6.7	6.3±5.2	0.031
Duration from diagnosis (years)	8.1±6.7	3.4±4.1	<0.001
Age of disease onset (years)	63.7±10.1	67.2±9.6	0.048
% predicted of post-BD FEV1	47.4±17.6	61.0±25.1	<0.001
GOLD staging
I	8 (5.8)	15 (21.1)	0.020
II	52 (38.0)	29 (40.8)
III	49 (35.8)	21 (29.6)
IV	28 (20.4)	6 (8.5)
Comorbidities
Diabetes mellitus	10 (7.3)	14 (19.7)	0.008
Hypertension	54 (39.4)	35 (49.3)	0.172
Dyslipidemia	22 (16.1)	21 (29.6)	0.022
Chronic kidney disease	9 (6.6)	5 (7.0)	0.897
Coronary artery disease	12 (87.3)	9 (12.7)	0.374
Malignancy	8 (5.8)	3 (4.2)	0.622
Severe AE
Rate	17 (12.4)	17 (23.9)	0.033
Number of severe AE (patient-years)	0.20±0.63	0.41±0.80	0.029

Notes: Results are expressed as mean ± standard deviation or n (%). Bold values indicate P-value reached statistical significance (<0.05).

Abbreviations: BD, bronchodilator; FEV₁, forced expiratory volume in the first second; GOLD, Global initiative for chronic Obstructive Lung Disease; AE, acute exacerbation.

Figure 1 Flowchart showing participation throughout the study.

Table 3 Use of COPD medications in Group A and Group B

Variables	Pulmonologist (Group A)	Internists (Group B)	P-value
	N=137	N=71
Pharmacological management
Reliever
Combined SABA + SAAC	136 (99.3)	71 (100)	0.471
Controller
Combined SABA + SAAC	5 (3.6)	12 (16.9)	0.001
LAAC alone	7 (5.1)	1 (1.4)	0.070
ICS alone	0 (0)	1 (1.4)	0.452
Combined ICS + LABA	69 (50.4)	48 (67.6)	0.337
Triple therapy (ICS + LABA + LAAC)	56 (40.9)	9 (12.7)	<0.001
Methylxanthines	97 (70.8)	45 (63.4)	0.275
Optimal pharmacological treatment corresponding to GOLD stages	136 (99.3)	69 (97.2)	0.231
I	8 (100.0)	15 (100.0)
II	52 (100.0)	28 (96.6)
III	49 (100.0)	21 (100.0)	0.231
IV	27 (96.4)	5 (83.3)
Non-pharmacological management
LTOT	20 (14.6)	9 (12.7)	0.704
Influenza vaccination in the past year	43 (31.4)	7 (9.9)	<0.001
Completion of pulmonary rehabilitation	33 (24.1)	0 (0.0)	<0.001
Optimal non-pharmacological management corresponding to GOLD stages	42 (30.7)	7 (9.9)	0.001
Education
Self-management plan	93 (67.9)	0 (0.0)	<0.001
Air pollution avoidance	137 (100.0)	12 (16.9)	<0.001

Notes: Results are expressed as n (%). Bold values indicate P-value reached statistical significance (<0.05).

Abbreviations: SABA, short-acting beta-2 agonist; SAAC, short-acting anticholinergic; LAAC, long-acting anticholinergic; ICS, inhaled corticosteroid; LABA, long-acting beta-2 agonist; GOLD, Global initiative for chronic Obstructive Lung Disease; LTOT, long-term oxygen therapy.

Table 4 Use of medications in COPD patients with severe acute exacerbation

Variables	Pulmonologist (Group A)	Internists (Group B)	P-value
	N=17	N=17
Reliever
Combined SABA + SAAC	17 (100.0)	17 (100.0)	–
Controller
Combined SABA + SAAC	0 (0.0)	2 (11.8)	0.145
LAAC alone	1 (5.8)	0 (0.0)	0.310
Combined ICS + LABA	10 (58.8)	14 (82.4)	0.545
Triple therapy	6 (30.4)	1 (5.8)	0.034
Methylxanthines	15 (88.2)	13 (76.5)	0.368
Other managements
LTOT	6 (35.3)	7 (41.2)	0.724
Influenza vaccine in the past year	1 (5.9)	2 (11.8)	0.545
Rehabilitation	1 (5.9)	0 (0.0)	0.310

Notes: Results are expressed as n (%). Bold value indicates P-value reached statistical significance (<0.05).

Abbreviations: SABA, short-acting beta-2 agonist; SAAC, short-acting anticholinergic; LAAC, long-acting anticholinergic; ICS, inhaled corticosteroid; LABA, long-acting beta-2 agonist; LTOT, long-term oxygen therapy.

Table 5 Characteristics of COPD patients with severe acute exacerbation

Variables	Pulmonologist (Group A)	Internists (Group B)	P-value
	N=29 episodes	N=29 episodes
The period before admission (days)	1 (1–10)	2 (1–7)	0.437
Cause
Infection	27 (93.2)	16 (55.2)	0.001
Poor compliance and inhalation technique	1 (3.4)	1 (3.4)	–
Pollution	1 (3.4)	12 (41.4)	0.001
Location of admission
Ward	20 (68.9)	23 (79.3)	0.539
Intensive care unit	9 (31.1)	6 (20.7)	0.368
Length of stay (days)
Ward	3.5 (1–20)	4.5 (2–11)	0.837
Intensive care unit	3.0 (1–7)	5.5 (2–29)	0.085
Total	4.0 (1–20)	6 (2–29)	0.265
Cost of treatment ($)
Drug	213 (15–793)	140 (16–1,655)	0.851
Laboratory	97 (3–513)	114 (0–865)	0.561
Chest radiography	9 (0–40)	7 (0–25)	0.203
Other	227 (80–1,574)	239 (22–4,023)	0.682
Total	612 (159–2,615)	494 (578–6,793)	0.657

Notes: Results are expressed as n (%) or median (range). Bold values indicate P-value reached statistical significance (<0.05).

Table 6 Results of treatment for COPD with severe acute exacerbation

Variables	Pulmonologist (Group A)	Internists (Group B)	P-value
	N=29 episodes	N=29 episodes
Resolved	29 (100.0)	27 (93.1)	0.150
Dead	0	2 (6.9)
Readmission with pneumonia	0	5 (17.2)	0.019

Notes: Results are expressed as n (%). Bold value indicates P-value reached statistical significance (<0.05).

Table 7 Characteristics of COPD with severe acute exacerbation requiring mechanical ventilator

Variables	Pulmonologist (Group A)	Internists (Group B)	P-value
	N=10 episodes	N=5 episodes
Mechanical ventilator (days)	1.5 (1–7)	5 (3–29)	0.005
Length of stay (days)
Ward	3 (1–14)	5.5 (4–11)	0.378
Intensive care unit	2 (1–7)	5 (2–29)	0.090
Total	3.5 (1–20)	16 (6–29)	0.012
Cost of treatment ($)
Drug	277 (101–648)	628 (140–1,655)	0.070
Laboratory	135 (12–441)	223 (140–865)	0.056
Chest radiography	22 (0–28)	51 (26–248)	0.022
Other	134 (134–1,574)	1,296 (259–4,023)	0.055
Total	863 (247–2,496)	2,095 (763–6,792)	0.049

Notes: Results are expressed as median (range). Bold values indicate P-value reached statistical significance (<0.05).