Eric L. Flenaugh

Impact of Comorbidities Among Medicaid Enrollees With Chronic Obstructive Pulmonary Disease, United States, 2009

Introduction Multimorbidity, the presence of 2 or more chronic conditions, frequently affects people with chronic obstructive pulmonary disease (COPD). Many have high-cost, highly complex conditions that have a substantial impact on state Medicaid programs. We quantified the cost of Medicaid-insured patients with COPD co-diagnosed with other chronic disorders. Methods We used nationally representative Medicaid claims data to analyze the impact of comorbidities (other chronic conditions) on the disease burden, emergency department (ED) use, hospitalizations, and total health care costs among 291,978 adult COPD patients. We measured the prevalence of common conditions and their influence on COPD-related and non–COPD-related resource use by using the Elixhauser Comorbidity Index. Elixhauser comorbidity counts were clustered from 0 to 7 or more. We performed multivariable logistic regression to determine the odds of ED visits by Elixhauser scores adjusting for age, sex, race/ethnicity, and residence. Results Acute care, hospital bed days, and total Medicaid-reimbursed costs increased as the number of comorbidities increased. ED visits unrelated to COPD were more common than visits for COPD, especially in patients self-identified as black or African American (designated black). Hypertension, diabetes, affective disorders, hyperlipidemia, and asthma were the most prevalent comorbid disorders. Substance abuse, congestive heart failure, and asthma were commonly associated with ED visits for COPD. Female sex was associated with COPD-related and non–COPD-related ED visits. Conclusion Comorbidities markedly increased health services use among people with COPD insured with Medicaid, although ED visits in this study were predominantly unrelated to COPD. Achieving excellence in clinical practice with optimal clinical and economic outcomes requires a whole-person approach to the patient and a multidisciplinary health care team.

Features of COPD as Predictors of Lung Cancer

Background: Lung cancer is a leading cause of death and hospitalization for patients with COPD. A detailed understanding of which clinical features of COPD increase risk is needed. Methods: We performed a nested case‐control study of Genetic Epidemiology of COPD (COPDGene) Study subjects with and without lung cancer, age 45 to 80 years, who smoked at least 10‐pack years to identify clinical and imaging features of smokers, with and without COPD, that are associated with an increased risk of lung cancer. The baseline evaluation included spirometry, high‐resolution chest CT scanning, and respiratory questionnaires. New lung cancer diagnoses were identified over 8 years of longitudinal follow‐up. Cases of lung cancer were matched 1:4 with control subjects for age, race, sex, and smoking history. Multiple logistic regression analyses were used to determine features predictive of lung cancer. Results: Features associated with a future risk of lung cancer included decreased FEV1/FVC (OR, 1.28 per 10% decrease [95% CI, 1.12–1.46]), visual severity of emphysema (OR, 2.31, none‐trace vs mild‐advanced [95% CI, 1.41–3.86]), and respiratory exacerbations prior to study entry (OR, 1.39 per increased events [0, 1, and ≥ 2] [95% CI, 1.04–1.85]). Respiratory exacerbations were also associated with small‐cell lung cancer histology (OR, 3.57 [95% CI, 1.47–10]). Conclusions: The degree of COPD severity, including airflow obstruction, visual emphysema, and respiratory exacerbations, was independently predictive of lung cancer. These risk factors should be further studied as inclusion and exclusion criteria for the survival benefit of lung cancer screening. Studies are needed to determine if reduction in respiratory exacerbations among smokers can reduce the risk of lung cancer.

Study Design and Rationale: A Multicenter, Prospective Trial of Electromagnetic Bronchoscopic and Electromagnetic Transthoracic Navigational Approaches for the Biopsy of Peripheral Pulmonary Nodules (ALL IN ONE Trial).

BACKGROUND Pulmonary nodules are a common but difficult issue for physicians as most identified on imaging are benign but those identified early that are cancerous are potentially curable. Multiple diagnostic options are available, ranging from radiographic surveillance, minimally invasive biopsy (bronchoscopy or transthoracic biopsy) to more invasive surgical biopsy/resection. Each technique has differences in diagnostic yield and complication rates with no established gold standard. Currently, the safest approach is bronchoscopic but it is limited by variable diagnostic yields. Percutaneous approaches are limited by nodule location and complications. With the recent advent of electromagnetic navigation (EMN), a combined bronchoscopic and transthoracic approach is now feasible in a single, staged procedure. Here, we present the study design and rationale for a single-arm trial evaluating a staged approach for the diagnosis of pulmonary nodules. METHODS Participants with 1-3 cm, intermediate to high-risk pulmonary nodules will undergo a staged approach with endobronchial ultrasound (EBUS) followed by EMN-bronchoscopy (ENB), then EMN-transthoracic biopsy (EMN-TTNA) with the procedure terminated at any stage after a diagnosis is made via rapid onsite cytopathology. We aim to recruit 150 EMN participants from eight academic and community settings to show significant improvements over other historic bronchoscopic guided techniques. The primary outcome is overall diagnostic yield of the staged approach. CONCLUSION This is the first study designed to evaluate the diagnostic yield of a staged procedure using EBUS, ENB and EMN-TTNA for the diagnosis of pulmonary nodules. If effective, the staged procedure will increase minimally invasive procedural diagnostic yield for pulmonary nodules.

Chronic plasma cell pneumonia in a patient with long-standing HIV infection.

Chronic bibasilar alveolar infiltrates existed for more than 2 years in a 25-year-old woman infected with HIV for more than a decade. Bronchoscopically, there were copious, purulent secretions that grew methicillin-resistant Staphylococcus aureus (MRSA). Transbronchial biopsy specimens demonstrated plasma cell interstitial pneumonia (PCIP). Focal, transient radiographic improvement occurred after antistaphylococcal antimicrobial therapy. With recurrent and progressive symptoms, sustained clinical and radiographic improvement did not occur until corticosteroid therapy was instituted with tuberculosis chemoprophylaxis. Persistent antigenic stimulation in immunosuppressed patients causes PCIP. In this instance, the stimulus is MRSA. The previous model and support for this theory is Pneumocystis carinii. There is good experimental reason for a plasma cell response in persons infected with HIV. To our knowledge, this is the first case of chronic plasma cell interstitial pneumonia caused by indolent MRSA infection.