The cost-effectiveness of antidepressants for smoking cessation in chronic obstructive pulmonary disease (COPD) patients

Objectives In healthy smokers, antidepressants can double the odds of cessation. Because of its four times lower costs and comparable efficacy in healthy smokers, nortriptyline appears to be favourable compared to bupropion. We assessed which of both drugs was most effective and cost‐effective in stopping smoking after 1 year compared with placebo among smokers at risk or with existing chronic obstructive pulmonary disease (COPD). Methods A total of 255 participants, aged 30–70 years, received smoking cessation counselling and were assigned bupropion, nortriptyline or placebo randomly for 12 weeks. Prolonged abstinence from smoking was defined as a participant's report of no cigarettes from week 4 to week 52, validated by urinary cotinine. Costs were calculated using a societal perspective and uncertainty was assessed using the bootstrap method. Results The prolonged abstinence rate was 20.9% with bupropion, 20.0% with nortriptyline and 13.5% with placebo. The differences between bupropion and placebo [relative risk (RR) = 1.6; 95% confidence interval (CI) 0.8–3.0] and between nortriptyline and placebo (RR = 1.5; 95% CI 0.8–2.9) were not significant. Severity of airway obstruction did not influence abstinence significantly. Societal costs were €1368 (2.5th–97.5th percentile 193–5260) with bupropion, €1906 (2.5th–97.5th 120–17 761) with nortriptyline and €1212 (2.5th–97.5th 96–6602) with placebo. Were society willing to pay more than €2000 for a quitter, bupropion was most likely to be cost‐effective. Conclusions Bupropion and nortriptyline seem to be equally effective, but bupropion appears to be more cost‐effective when compared to placebo and nortriptyline. This impression holds using only health care costs. As the cost‐effectiveness analyses concern some uncertainties, the results should be interpreted with care and future studies are needed to replicate the findings.     

戒烟对稳定期慢性阻塞性肺疾病的治疗作用

目的探讨戒烟对稳定期COPD的治疗作用。方法纳入2011年7月-2013年7月经福建医科大学附属泉州第一医院肺功能室检查确诊的稳定期COPD患者193例,按是否采用戒烟治疗及最终完成情况分为戒烟成功组、戒烟失败组及非戒烟组：戒烟成功亚组62例,均为男性,平均年龄为（60．82±5．63）岁,平均吸烟指数为（852±100）年·支;戒烟失败亚组36例,均为男性,平均年龄为（60．61±4．91）岁,平均吸烟指数为（812±139）年·支;非戒烟组95例,均为男性,平均年龄为（60．49±8．77）岁,平均吸烟指数为（833土143）年·支。采用FEV。为肺功能评价指标,CAT评分为COPD病情评价指标。进行为期半年的随访。结果各试验组患者在年龄、体质量指数及吸烟指数等方面差异无统计学意义。戒烟成功组患者治疗后体质量增加（2．85±1．27）kg,CAT评分下降（6．05±2．60）分,戒烟前后对比差异有统计学意义（t值分别为17．763、18．351,P值均d0．01）;FEV,增加（O．04±0．18）L,戒烟前后对比差异无统计学意义（t=1．900,P=0．062）。而戒烟失败组及未戒烟组治疗前后体质量、CAT评分及FEV,变化差异均无统计学意义（P值均〉0．05）。结论戒烟半年即对稳定期COPD具有=定的治疗作用,主要表现在体质量增加、临床症状减轻,而肺功能则无明显改善。     

Cost-effectiveness of smoking cessation and the implications for COPD

The cost burden of COPD is substantial for patients and families, payers, and society as a whole. Smoking has been known for decades to be the leading cause of the disease. Numerous studies have been completed to address the cost-effectiveness of programs created to aid smokers in their efforts to quit. Because several assumptions must be made in order to conduct such a study, and because differences in study design are numerous, comparison of data is difficult. However, studies have consistently shown that regardless of the perspective from which the study was completed, or the methods used to help smokers abstain, the interventions are cost-effective. Although no study has been conducted specifically to assess the cost-effectiveness of smoking cessation interventions as they relate directly to patients with COPD, based on current data it can be concluded that smoking cessation programs are cost-effective for this population.     

慢性肺病住院患者戒烟成功影响因素研究

目的研究住院慢性肺病患者相对于其他住院患者吸烟行为特征的特点及戒烟成功相关影响因素。方法在2014年6月至2015年6期间肺病科连续的慢性肺病住院患者,配对抽取同期于其他科室住院的非慢性肺病患者,填写调查表进行数据分析。结果本调查中吸烟患者均以控制不住烟瘾为继续吸烟主要原因;在慢性肺病患者分组中主要以经济原因为主要戒烟原因,而在非慢性肺病分组中主要以防未病为主;吸烟人群中,大家对戒烟行为的认知是一致的,在戒烟过程中不仅取决于本人的态度是否坚决,还与其对整个过程的信心及外界环境息息相关;在戒烟过程中,戒烟持续时间在很大程度上决定戒烟是否成功。多因素Logistic回归分析发现年龄、月经济收入、饮酒、是否患有其他慢性病、自觉健康状况、尼古丁依赖均影响是否戒烟成功。结论目前慢性肺病患者戒烟能够成功很大程度上是因为随着年龄增大及疾病的进行性加重及经济条件不佳所"被迫"成功的,提示我们在今后的戒烟治疗中,应早期干预,变被动戒烟为主动戒烟。     

COPD患者伴发抑郁障碍及其相关因素的研究

目的了解慢性阻塞性肺病（chronic obstructive pulmonary disease,COPD）患者伴发抑郁障碍的情况,并分析其可能的影响因素。方法运用ZUNG抑郁自评量表对87例COPD患者伴发抑郁障碍的情况进行调查,依据患者的年龄、性别、文化程度、付费方式、患病时间及住院次数等因素进行分组研究,应用SPSS10．0统计软件进行数据的统计学检验。结果48．2％的COPD住院患者合并有不同程度的抑郁障碍。其中女性患者、大学或大学以上文化程度的患者、小学文化程度和文盲患者、自费患者伴发抑郁障碍的比例较高;而住院次数及年龄则不影响合并抑郁障碍的情况。结论COPD住院患者伴发抑郁障碍的比例较高,性别、文化程度、付费方式等是其主要影响因素。     

The costs of exacerbations in chronic obstructive pulmonary disease (COPD)

Exacerbations are the key drivers in the costs of chronic obstructive pulmonary disease (COPD). The objective was to examine the costs of COPD exacerbations in relation to differing degrees of severity of exacerbations and of COPD. We identified 202 subjects with COPD, defined according to the BTS and ERS criteria. Exacerbations were divided into mild (self-managed), mild/moderate (telephone contact with a health-care centre and/or the use of antibiotics/systemic corticosteroids), moderate (health-care centre visits) and severe (emergency care visit or hospital admission). Exacerbations were identified by sending the subjects a letter inquiring whether they had any additional respiratory problems or influenza the previous winter. At least one exacerbation was reported by 61 subjects, who were then interviewed about resource use for these events. The average health-care costs per exacerbation were SEK 120 (95% C=39-246), SEK 354 (252-475), SEK 2111 (1673-2612) and SEK 21852 (14436-29825) for mild, mild/moderate, moderate and severe exacerbations, respectively. Subjects with impaired lung function experienced more severe exacerbations, which was also reflected in the cost of exacerbations per severity of the disease during the 4 1/2 month study period (ranging from SEK 224 for mild to SEK 13708 for severe cases, median SEK 940). Exacerbations account for 35-45% of the total per capita health-care costs for COPD. In conclusion, costs varied considerably with the severity of the exacerbation as well as with the severity of COPD. The prevention of moderate-to-severe exacerbations could be very cost-effective and improve the quality of life.     

Autonomic dysfunction in patients with chronic obstructive pulmonary disease (COPD)

It has been recognized that chronic obstructive pulmonary disease (COPD) is a systemic disease which has been shown to negatively affect the cardiovascular and autonomic nerve system. The complexity of the physiologic basis by which autonomic dysfunction occurs in patients with COPD is considerable and the knowledge in this field remains elementary. The purpose of this review is to provide an overview of important potential mechanisms which might affect the autonomic nervous system in patients with COPD. This review aims to summarize the basic research in the field of autonomic dysfunction in patients with COPD. In COPD patients the activity of sympathetic nerves may be affected by recurrent hypoxemia, hypercapnia, increased intrathoracic pressure swings due to airway obstruction, increased respiratory effort, systemic inflammation and the use of betasympathomimetics. Furthermore, experimental findings suggest that autonomic dysfunction characterized by a predominance of sympathetic activity can significantly modulate further inflammatory reactions. The exact relationship between autonomic dysfunction and health status in COPD remains to be elucidated. Treatment aimed to restore the sympathovagal balance towards a reduction of resting sympathetic activity may modulate the inflammatory state, and possibly contributes to improved health status in COPD.     

Predictors of long-term survival in elderly patients hospitalized for acute exacerbations of chronic obstructive pulmonary disease

Background and objective: There is a paucity of survival data regarding the prognosis of elderly patients following acute exacerbations of COPD (AECOPD). We undertook a study to examine long‐term mortality rates and to identify clinical and laboratory predictors of these outcomes. Methods: A retrospective cohort study was conducted of 786 consecutive elderly (>65 years) patients admitted to general medicine acute‐care wards for AECOPD. Factors determining short‐ and long‐term mortality were analysed. Results: The mean (±SD) age of the study population was 75.8 ± 7.3 years (range 65–100 years). The in‐hospital mortality rate for the entire cohort was 7.25%. The risk of mortality at 1, 3 and 5 years was 28%, 47% and 54%, respectively. In univariate analysis age (hazard ratio 1.52; 95% confidence interval: 1.23–1.91), FEV₁ (1.45; 1.73–2.35), active cancer (1.23; 1.64–2.32), current smoking (1.74; 1.35–2.11), ischaemic heart disease (1.58; 1.28–2.02), congestive heart failure (1.55; 1.23–2.26) and maintenance use of oral glucocorticosteroids (1.58; 1.11–2.79) were significantly associated with mortality. In multivariate analysis, only current smoking (1.89; 1.18–1.93), ischaemic heart disease (1.41; 1.07–1.68), PaCO₂ on admission (1.49; 1.03–1.60), hospital readmission (2.23; 1.40–2.18) and FEV₁ (1.41; 1.12–1.54) were independent predictors of mortality. Conclusions: This study provides new insights into the predictive factors associated with long‐term prognosis in elderly patients admitted for acute exacerbations of COPD, which differ from those previously identified for younger patients.     

BiPAP呼吸机治疗COPD呼吸衰竭的疗效观察

目的探讨鼻（面）罩双水平气道正压通气（BiPAP）对慢性阻塞性肺疾病（COPD）呼吸衰竭的治疗作用。方法观察48例COPD呼吸衰竭患者应用BiPAP呼吸机辅助治疗前后患者血气变化及临床情况的变化。结果48例中好转45例（93．75％）,患者PaO2,SaO2明显上升,PaCO2明显下降,临床情况改善。3例因病情加重改为有创通气。结论BiPAP呼吸机辅助通气治疗COPD呼吸衰竭疗效肯定,减少了气管插管和气管切开,有利于患者康复。     

无创正压通气治疗慢性阻塞性肺病急性加重期并发Ⅱ型呼吸衰竭临床分析

目的　研究无创正压通气(NIPPV)治疗慢性阻塞性肺病急性加重期并发Ⅱ型呼吸衰竭的临床效果。方法　1999-01~2004-06深圳铁路医院呼吸内科观察23例NIPPV治疗慢性阻塞性肺病(COPD)急性加重期并发Ⅱ型呼吸衰竭患者的血气指标变化(pH值,PaO2,PaCO2 ),住院病程,气管插管率和病死率,并同以往未使用NIPPV治疗的25例COPD相似病例进行比较分析。结果　23例NIPPV治疗前后24h血气指标明显改善,住院病程缩短,气管插管率和住院病死率明显降低,同非NIPPV治疗的对照组比较差异有显著性。NIPPV组中,重度呼吸衰竭的气管插管率明显高于轻中度呼吸衰竭(P<0 .05 )。结论　NIPPV是治疗慢性阻塞性肺病急性加重期并发Ⅱ型呼吸衰竭的一种有效方法,早期应用可能阻止病情进一步发展,缩短病程。     

Nutritional status and long-term mortality in hospitalised patients with chronic obstructive pulmonary disease (COPD)

Patients with chronic obstructive pulmonary disease (COPD) often have difficulties with keeping their weight. The aim of this investigation was to study nutritional status in hospitalised Nordic COPD patients and to investigate the association between nutritional status and long-term mortality in this patient group. In a multicentre study conducted at four university hospitals (Reykjavik, Uppsala, Tampere and Copenhagen) hospitalised patients with COPD were investigated. Patient height, weight and lung function was recorded. Health status was assessed with St. George's Hospital Respiratory Questionnaire. After 2 years, mortality data was obtained from the national registers in each country. Of the 261 patients in the study 19% where underweight (BMI <20), 41% were of normal weight (BMI 20-25), 26% were overweight (BMI 25-30) and 14% were obese. FEV(1) was lowest in the underweight and highest in the overweight group (p=0.001) whereas the prevalence of diabetes and cardio-vascular co-morbidity went the opposite direction. Of the 261 patients 49 (19%) had died within 2 years. The lowest mortality was found among the overweight patients, whereas underweight was related to increased overall mortality. The association between underweight in COPD-patients, and mortality remained significant after adjusting for possible confounders such as FEV(1) (hazard risk ratio (95% CI) 2.6 (1.3-5.2)). We conclude that COPD patients that are underweight at admission to hospital have a higher risk of dying within the next 2 years. Further studies are needed in order to show whether identifying and treating weight loss and depletion of fat-free mass (FFM) is a way forward in improving the prognosis for hospitalised COPD patients.     

Success of smoking cessation in patients with chronic obstructive pulmonary disease

Smoking causes chronic obstructive pulmonary disease (COPD) in 15 to 20% of smokers. Smoking accelerates the annual rate of FEV(1) decline, whereas it was demonstrated that smoking cessation is the major factor that reduces this decline. The aims of this prospective study were to assess the success rate and factors affecting smoking cessation, besides, to evaluate the effect of cessation on annual FEV(1) decline. Sixty-five consecutive patients with COPD and as a control group 50 ageand sex-matched healthy smokers who were admitted to our smoking cessation clinic were enrolled in the study. Intensive behavioral therapy alone or with nicotine replacement therapy or bupropion HCL was given to both groups and success rate of smoking cessation after one year was assessed. It was shown that demographic features of the subjects and the history of COPD had no effect on success of smoking cessation. At the end of one year the rate of smoking cessation was 29% in patients with COPD and 49% in the control group (p< 0.05). All different therapy interventions had similar effects on smoking cessation. The annual FEV(1) values increased 29 mL in quitters and decreased 25 mL in patients continuing smoking (p> 0.05). In this study, we concluded that the success of smoking cessation in COPD patients admitted to the smoking cessation clinic was significantly lower than healthy smokers and annual FEV(1) decline was decreased in quitters.     

Association of gastroesophageal reflux disease risk with exacerbations of chronic obstructive pulmonary disease

Gastroesophageal reflux disease (GERD) may be a potential risk factor for exacerbations of chronic obstructive pulmonary disease (COPD). The aim of the present study was to explore the association of GERD risk with exacerbations of COPD. Patients with COPD were consecutively recruited, and COPD Assessment Test (CAT) and Reflux Diagnostic Questionnaire (RDQ) were administered. If the CAT score was 5 points higher than that taken in the stable states, the patient was considered as having exacerbations of COPD. A RDQ score of ≥12 is defined high GERD risk. Univariate and multivariate logistic regression analyses were performed to evaluate the relationship between high GERD risk and exacerbations of COPD. Among 386 patients with COPD, the mean CAT score was 18.3 ± 6.6, and 76 (19.7%) patients had exacerbations during the 1‐year follow‐up. The mean RDQ score was 10.1 ± 4.7, and 132 (34.2%) patients were identified as having high GERD risk. Multivariate logistic regression analyses revealed that the high GERD risk (odds ratio, 2.31; 95% confidence interval, 1.29–3.87) was an independent risk factor of COPD exacerbations. In conclusion, high GERD risk appears to be associated with higher odds for COPD exacerbations.     

Benefits of smoking cessation with focus on cardiovascular and respiratory comorbidities

Smoking cessation is crucial in preventing premature morbidity, disability and mortality worldwide. The effectiveness of quitting tobacco use surpasses any other intervention to minimise the risk for chronic cardiac and respiratory conditions. The overall health benefits of smoking cessation have been recognised for decades but as tobacco legislation has been changing in recent years, new evidence particularly concerning the effect of less smoke exposure on the vascular system has emerged. Recently, much research in chronic obstructive pulmonary disease (COPD) has concerned the ongoing inflammation - also in former smokers - and disease heterogeneity, which provides new knowledge regarding current and ex-smokers with COPD. Many other cardiovascular and respiratory diseases are associated with smoking, and the course of these diseases is not always studied in the context of smoking cessation versus continued smoking. This review summarises the latest available data on health benefits of smoking cessation with focus on both common and infrequent cardiovascular and respiratory diseases.     

The effect of a respiratory home nurse intervention in patients with chronic obstructive pulmonary disease (COPD)

Background : Chronic obstructive pulmomary disease (COPD) is associated with substantial mortality, morbidity, and costs to the health care system. With the increasing interest in outreach care programmes it is important to evaluate their impact upon patients and health services, for conditions such as COPD.
Aim : To determine the effectiveness of an outreach respiratory nurse in a shared care approach, with collaboration between general practitioners and hospital services, in the management of patients with severe COPD.
Methods : Patients with severe COPD attending The Queen Elizabeth Hospital, Adelaide participated in a randomised controlled trial of a home based nursing intervention (HBNI) over 12 months with outcome measures including mortality rate, hospital service utilisation, FEV₁ and health related quality of life (HRQL) using a modified Dartmouth Primary Care Co-operative Quality of Life questionnaire.
Results : There were 48 subjects in each study arm, with no differences in mortality rate (eight deaths in the HBNI group and seven in the control group), hospital admissions, length of stay, number of outpatient and Emergency Service visits. The study had inadequate follow-up of FEV₁ and HRQL within the control group. Within the HBNI group, a small improvement in HRQL (in three of ten indices measured) was demonstrated, despite a deterioration in FEV₁ (11% reduction, p =0.04) compared to baseline. Quality of life of HBNI subjects' carers did not change.
Conclusion : An increased level of care given by an outreach respiratory nurse in a shared care approach for patients with severe COPD produced small improvements in HRQL but did not result in the prevention of deaths or reduced health care utilisation.