Impact of PAP therapy on hospitalization rates in Medicare beneficiaries with COPD and coexisting OSA.

OBJECTIVE: Growing evidence supports that patients with chronic obstructive pulmonary disease (COPD) and coexisting obstructive sleep apnea (OSA) have poor prognosis. This association is described as overlap syndrome. Positive airway pressure (PAP) therapy is now the preferred treatment for OSA. We hypothesized that use of PAP therapy in elderly patients with overlap syndrome would be associated with lower healthcare utilization. METHODS: In this retrospective cohort study, we analyzed data from 5% national sample of fee-for-service Medicare beneficiaries with a diagnosis of COPD who were newly started on PAP therapy in 2011. We examined the effect of PAP therapy on emergency room (ER) visits and hospitalizations for all-cause and COPD-related conditions in the 1 year pre- and 1 year post-initiation of PAP therapy. RESULTS: In year 2011, we identified 319 patients with overlap syndrome who were new users of PAP therapy. In this cohort of patients, hospitalization rates for COPD-related conditions were significantly lower in the 1 year post-initiation of PAP therapy compared to the 1-year pre-initiation period (19.4 vs 25.4%, P value = 0.03). However, ER visits (for any cause or COPD-related conditions) and hospitalization rates for any cause did not differ significantly in the pre- and post-initiation periods. PAP therapy was more beneficial in older adults, those with higher COPD complexity, and those with three or more comorbidities. CONCLUSION: Initiation of PAP therapy in elderly patients with overlap syndrome is associated with a reduction in hospitalization for COPD-related conditions, but not for all-cause hospitalizations and ER visits.

Process and Outcome Measures among COPD Patients with a Hospitalization Cared for by an Advance Practice Provider or Primary Care Physician.

OBJECTIVES: To examine the process and outcomes of care of COPD patients by Advanced Practice Providers (APPs) and primary care physicians. METHODS: We conducted a cross sectional retrospective cohort study of Medicare beneficiaries with COPD who had at least one hospitalization in 2010. We examined the process measures of receipt of spirometry evaluation, influenza and pneumococcal vaccine, use of COPD medications, and referral to a pulmonary specialist visit. Outcome measures were emergency department (ER) visit, number of hospitalizations and 30-day readmission in 2010. RESULTS: A total of 7,257 Medicare beneficiaries with COPD were included. Of these, 1,999 and 5,258 received primary care from APPs and primary care physicians, respectively. Patients in the APP group were more likely to be white, younger, male, residing in non-metropolitan areas and have fewer comorbidities. In terms of process of care measures, APPs were more likely to prescribe short acting bronchodilators (adjusted odds ratio [aOR] = 1.18, 95%Confidence Interval [CI] 1.05-1.32), oxygen therapy (aOR = 1.25, 95% CI 1.12-1.40) and consult a pulmonary specialist (aOR = 1.39, 95% CI 1.23-1.56), but less likely to give influenza and pneumococcal vaccinations. Patients receiving care from APPs had lower rates of ER visits for COPD (aOR = 0.84, 95%CI 0.71-0.98) and had a higher follow-up rate with pulmonary specialist within 30 days of hospitalization for COPD (aOR = 1.25, 95%CI 1.07-1.48) than those cared for by physicians. CONCLUSIONS: Compared to patients cared for by physicians, patients cared for by APPs were more likely to receive short acting bronchodilator, oxygen therapy and been referred to pulmonologist, however they had lower rates of vaccination probably due to lower age group. Patients cared for by APPs were less like to visit an ER for COPD compared to patients care for by physicians, conversely there was no differences in hospitalization or readmission for COPD between MDs and APPs.