Mode of delivery and birth outcomes before and during COVID-19 -A population-based study in Ontario, Canada.

There is lack of clarity on whether pregnancies during COVID-19 resulted in poorer mode of delivery and birth outcomes in Ontario, Canada. We aimed to compare mode of delivery (C-section), birth (low birthweight, preterm birth, NICU admission), and health services use (HSU, hospitalizations, ED visits, physician visits) outcomes in pregnant Ontario women before and during COVID-19 (pandemic periods). We further stratified for pre-existing chronic diseases (asthma, eczema, allergic rhinitis, diabetes, hypertension). Deliveries before (Jun 2018-Feb 2020) and during (Jul 2020-Mar 2022) pandemic were from health administrative data. We used multivariable logistic regression analyses to estimate adjusted odds ratios (aOR) of delivery and birth outcomes, and negative binomial regression for adjusted rate ratios (aRR) of HSU. We compared outcomes between pre-pandemic and pandemic periods. Possible interactions between study periods and covariates were also examined. 323,359 deliveries were included (50% during pandemic). One in 5 (18.3%) women who delivered during the pandemic had not received any COVID-19 vaccine, while one in 20 women (5.2%) lab-tested positive for COVID-19. The odds of C-section delivery during the pandemic was 9% higher (aOR = 1.09, 95% CI: 1.08-1.11) than pre-pandemic. The odds of preterm birth and NICU admission were 15% (aOR = 0.85, 95% CI: 0.82-0.87) and 10% lower (aOR = 0.90, 95% CI: 0.88-0.92), respectively, during COVID-19. There was a 17% reduction in ED visits but a 16% increase in physician visits during the pandemic (aRR = 0.83, 95% CI: 0.81-0.84 and aRR = 1.16, 95% CI: 1.16-1.17, respectively). These aORs and aRRs were significantly higher in women with pre-existing chronic conditions. During the pandemic, healthcare utilization, especially ED visits (aRR = 0.83), in pregnant women was lower compared to before. Ensuring ongoing prenatal care during the pandemic may reduce risks of adverse mode of delivery and the need for acute care during pregnancy.

Impact of surgical lung biopsy on lung function and survival in patients with idiopathic pulmonary fibrosis in a multi-centre registry cohort.

BACKGROUND AND OBJECTIVE: Establishing an accurate and timely diagnosis of idiopathic pulmonary fibrosis (IPF) is essential for appropriate management and prognostication. In some cases, surgical lung biopsy (SLB) is performed but carries non-negligible risk. The objective of this retrospective study was to determine if SLB is associated with accelerated lung function decline in patients with IPF using the Canadian Registry for Pulmonary Fibrosis. METHODS: Linear mixed models and Cox proportional hazards regression models were used to compare decline in forced vital capacity (FVC)%, diffusion capacity of the lung (DLCO%) and risk of death or lung transplantation between SLB and non-SLB patients. Adjustments were made for baseline age, sex, smoking history, antifibrotic use, and lung function. A similar analysis compared lung function changes 12 months pre- and post-SLB. RESULTS: A total of 81 SLB patients and 468 non-SLB patients were included. In the SLB group, the post-biopsy annual FVC% decline was 2.0% (±0.8) in unadjusted, and 2.1% (±0.8) in adjusted models. There was no difference in FVC% decline, DLCO% decline, or time to death or lung transplantation between the two groups, in adjusted or unadjusted models (all p-values >0.07). In the pre-post SLB group, no differences were identified in FVC% decline in unadjusted or adjusted models (p = 0.07 for both). CONCLUSION: No association between SLB and lung function decline or risk of death or lung transplantation was identified in this multi-centre study of patients with IPF.

The relationship between the morningness-eveningness questionnaire and incident cancer: A historical clinical cohort study.

OBJECTIVE: We conducted a retrospective cohort study to explore the relationship between chronotype measured by the total Morningness-Eveningness Questionnaire (MEQ) score and incident cancer. METHODS: We used clinical and provincial health administrative data on consecutive adults who underwent a Level 1 Polysomnography (PSG) and completed the MEQ between 2010 and 2015 in an academic hospital (Ontario, Canada) and were cancer-free at baseline. Cancer status was derived from the Ontario Cancer Registry. Individuals were followed until death or March 31, 2020. We used multivariable Cox cause-specific regressions to address the research objective. RESULTS: Of 3,004 individuals, 1,781 were analyzed: a median age of 54 years (IQR: 40-64) and 838 (47.1%) men. The median total MEQ score was 63 (IQR: 55-69); 61 (3.4%) were classified as evening (≤41), 536 (30.1%) as intermediate (42-58), and 1,184 (66.5%) as morning chronotypes (≥59). Over a median of 7 years (IQR: 5-8), 120 (6.7%) developed cancer. A U-shape relationship was found between the total MEQ score and an increased hazard of incident cancer, controlling for PSG measures of sleep apnea severity and sleep architecture, demographics, and comorbidities. Compared to the median of 63.0, a total MEQ score greater or less than the median was associated with an increased hazard of incident cancer, with the largest effect for those with a total score ≥76 (e.g., HR of a MEQ total score of 78 vs. 63: 2.01, 95% CI: 1.09-3.71). CONCLUSION: The U-shaped curve may reflect deviations from a standard circadian tendency, which may stress biological systems and influence malignancy risk.

Feasibility of a wearable self-management application for patients with COPD at home: a pilot study.

BACKGROUND: Among people with COPD, smartphone and wearable technology may provide an effective method to improve care at home by supporting, encouraging, and sustaining self-management. The current study was conducted to determine if patients with COPD will use a dedicated smartphone and smartwatch app to help manage their COPD and to determine the effects on their self-management. METHODS: We developed a COPD self-management application for smartphones and smartwatches. Participants were provided with the app on a smartphone and a smartwatch, as well as a cellular data plan and followed for 6 months. We measured usage of the different smartphone app functions. For the primary outcome, we examined the change in self-management from baseline to the end of follow up. Secondary outcomes include changes in self-efficacy, quality of life, and COPD disease control. RESULTS: Thirty-four patients were enrolled and followed. Mean age was 69.8 years, and half of the participants were women. The most used functions were recording steps through the smartwatch, entering a daily symptom questionnaire, checking oxygen saturation, and performing breathing exercises. There was no significant difference in the primary outcome of change in self-management after use of the app or in overall total scores of health-related quality of life, disease control or self-efficacy. CONCLUSION: We found older patients with COPD would engage with a COPD smartphone and smartwatch application, but this did not result in improved self-management. More research is needed to determine if a smartphone and smartwatch application can improve self-management in people with COPD. TRIAL REGISTRATION: ClinicalTrials.Gov NCT03857061, First Posted February 27, 2019.

Impressions and Perceptions of a Smartphone and Smartwatch Self-Management Tool for Patients With COPD: A Qualitative Study.

BACKGROUND: Patients with chronic obstructive pulmonary disease (COPD) often do not seek care until they experience an exacerbation. Improving self-management for these patients may increase health-related quality of life and reduce hospitalizations. Patients are willing to use wearable technology for real-time data reporting and perceive mobile technology as potentially helpful in COPD management, but there are many barriers to the uptake of these technologies. OBJECTIVE: We aimed to understand patients' experiences using a wearable and mobile app and identify areas for improvement. METHODS: We conducted semi-structured interviews as part of a larger prospective cohort study wherein patients used a wearable and app for 6 months. We asked which features patients found accessible, acceptable and useful. RESULTS: We completed 26 interviews. We summarized our research findings into four main themes: (1) information, support and reassurance, (2) barriers to adoption, (3) impact on communication with health care providers, and (4) opportunities for improvement. Most patients found the feedback received through the app to be reassuring and useful. Some patients experienced technical difficulties with the app and found the wearable to be uncomfortable. CONCLUSIONS: Patients found a wearable device and mobile application to be acceptable and useful for the management of COPD. We identified barriers to adoption and opportunities for improvement to the design of our app. Further research is needed to understand what people with COPD and their healthcare providers want and will use in a mobile app and wearable for COPD management.

Acceptability of the Long-Term In-Home Ventilator Engagement virtual intervention for home mechanical ventilation patients during the COVID-19 pandemic: A qualitative evaluation.

Background: Clinical management of ventilator-assisted individuals (VAIs) was challenged by social distancing rules during the COVID-19 pandemic. In May 2020, the Long-Term In-Home Ventilator Engagement (LIVE) Program was launched in Ontario, Canada to provide intensive digital care case management to VAIs. The purpose of this qualitative study was to explore the acceptability of the LIVE Program hosted via a digital platform during the COVID-19 pandemic from diverse perspectives. Methods: We conducted a qualitative descriptive study (May 2020-April 2021) comprising semi-structured interviews with participants from eight home ventilation specialty centers in Ontario, Canada. We purposively recruited patients, family caregivers, and providers enrolled in LIVE. Content analysis and the theoretical concepts of acceptability, feasibility, and appropriateness were used to interpret findings. Results: A total of 40 individuals (2 VAIs, 18 family caregivers, 20 healthcare providers) participated. Participants described LIVE as acceptable as it addressed a longstanding imperative to improve care access, ease of use, and training provided; feasible for triaging problems and sharing information; and appropriate for timeliness of provider responses, workflows, and perceived value. Negative perceptions of acceptability among healthcare providers concerned digital workload and fit with existing clinical workflows. Perceived benefits accorded to LIVE included enhanced physical and psychological safety in the home, patient-provider relations, and VAI engagement in their own care. Conclusions: Study findings identify factors influencing the LIVE Program's acceptability by patients, family caregivers, and healthcare providers during pandemic conditions including enhanced access to care, ease of case management triage, and VAI safety. Findings may inform the implementation of digital health services to VAIs in non-pandemic circumstances.

Early versus late onset interstitial lung disease in rheumatoid arthritis: An observational study of risk factors and mortality in Ontario, Canada.

BACKGROUND AND OBJECTIVE: Interstitial lung disease (ILD) can occur as a manifestation of rheumatoid arthritis (RA) at various times in the disease course. We aimed to identify factors associated with early versus late onset RA-ILD and how the timing of RA-ILD influenced surgical lung biopsy completion and mortality. METHODS: We performed a retrospective observational study using health services data from Ontario, Canada. We identified RA cases between 2000 and 2020 using the Ontario Rheumatoid Arthritis Database. RA-ILD diagnosis required repeat physician visits for ILD, with early RA-ILD defined as within 1 year of RA diagnosis. We performed multivariable logistic regression to identify factors associated with early RA-ILD and surgical lung biopsy completion, and multivariable cox-proportional hazards regression to evaluate the association of early versus late RA-ILD on all-cause and RA-ILD related mortality. RESULTS: In total, we identified 3717 cases of RA-ILD. Older age at RA diagnosis [OR 1.04 (95%CI 1.03-1.05), p < 0.0001], female sex [OR 1.16 (95%CI 1.01-1.35), p = 0.04] and immigrating to Ontario [OR 1.70 (95%CI 1.35-2.14), p < 0.0001] was associated with early RA-ILD. Patients with early versus late RA-ILD experienced similar odds of undergoing a surgical lung biopsy [OR 1.34 (95%CI 0.83-2.16), p = 0.23]. Early RA-ILD was associated with increased all-cause mortality [HR 1.17 (95%CI 1.07-1.29), p = 0.0009], primarily driven by an increase in RA-ILD related mortality [HR 1.45 (95%CI 1.19-1.76), p = 0.0003]. CONCLUSION: Age at RA onset, female sex and immigration status are associated with early RA-ILD. Patients with early RA-ILD experience increased all-cause and RA-ILD related mortality after adjusting for demographics and comorbidities.

Characteristics and risk factors of interstitial pneumonia with autoimmune features.

BACKGROUND: Interstitial pneumonia with autoimmune features (IPAF) has features of connective tissue disease-associated interstitial lung disease (CTD-ILD), but without meeting criteria for a specific CTD. We compared baseline characteristics, survival, and response to treatment of IPAF to both CTD-ILD and unclassifiable ILD. METHODS: Measurements were extracted from a prospective registry. Baseline features and survival were compared in IPAF against both CTD-ILD and unclassifiable ILD. Linear trajectory of lung function decline (%-predicted forced vital capacity [FVC%] and diffusion capacity of the lung for carbon monoxide [DLCO%]) before and after initiation of mycophenolate or azathioprine were compared in IPAF against both CTD-ILD and unclassifiable ILD using linear mixed models. RESULTS: Compared to CTD-ILD (n = 1240), patients with IPAF (n = 128) were older, more frequently male, and had greater smoking history. Compared to unclassifiable ILD (n = 665), patients with IPAF were younger, more frequently female, and had worse baseline lung function. IPAF had higher mortality compared to CTD-ILD and similar risk of mortality compared to unclassifiable ILD. Mycophenolate initiation was associated with stabilization of FVC% and DLCO% in all ILD subtypes except for FVC% in patients with IPAF, and azathioprine initiation with stabilization of FVC% and DLCO% in all ILD subtypes except for FVC% decline in IPAF and DLCO% decline in CTD-ILD. CONCLUSION: Patients with IPAF had worse survival compared to those with CTD-ILD and similar mortality to unclassifiable ILD, with treatment being associated with stabilization in lung function in all three ILDs. It is uncertain whether IPAF should be considered a distinct ILD diagnostic subgroup.

Impact of chronic obstructive pulmonary disease on lung cancer symptom burden: a population-based study in Ontario, Canada.

Background: Chronic obstructive pulmonary disease (COPD) and lung cancer commonly coexist and have significant symptom overlap. We sought to compare the symptom burden of lung cancer patients with COPD to those without COPD. Methods: We conducted a retrospective, cross-sectional study of stage I-IV lung cancer patients in Ontario, Canada, who completed the Edmonton Symptom Assessment Scale (ESAS) within 90 days of diagnosis. COPD was ascertained using a validated algorithm and patients were grouped as: no COPD, previously diagnosed COPD (at least 90 days prior to lung cancer diagnosis), and newly diagnosed COPD (within 90 days of lung cancer diagnosis). The association between COPD status and any moderate to severe symptom (ESAS ≥4) and the number of moderate to severe symptoms was determined using multivariable modified Poisson regression analyses. Multivariable linear regression analysis was used to compare total symptom distress scores. Analyses were stratified by limited (I/II) and advanced stage (III/IV). Results: Among 38,898 lung cancer patients, 53% had COPD (previously diagnosed 43%, newly diagnosed 10%). Collectively, those with previously diagnosed COPD had the most severe symptom burden. Across all stages, both COPD groups had a significantly higher risk of experiencing any (relative risk: 1.04 to 1.18) and multiple moderate to severe symptoms (RR 1.05 to 1.24), in addition to higher total symptom distress scores (P<0.0001). Differences in symptom burden between groups were most pronounced among early-stage patients. Conclusions: Lung cancer patients with underlying COPD have worse symptom burden, indicating a need for interventions that effectively alleviate symptoms.

Pandemic Effect on Healthcare Use and Death in Adults with Epilepsy: A Population Study.

OBJECTIVES: We conducted a population-based study using Ontario health administrative data to describe trends in healthcare utilization and mortality in adults with epilepsy during the first pandemic year (March 2020-March 2021) compared to historical data (2016-2019). We also investigated if changes in outpatient visits and diagnostic testing during the first pandemic year were associated with increased risk for hospitalizations, emergency department (ED) visits, or death. METHODS: Projected monthly visit rates (per 100,000 people) for outpatient visits, electroencephalography, magnetic resonance, computed tomography, all-cause ED visits, hospitalizations, and mortality were calculated based on historical data by fitting monthly time series autoregressive integrated moving-average models. Two-way interactions were calculated using Quasi-Poisson models. RESULTS: In adults with epilepsy during the first quarter of the pandemic, we demonstrated a reduction in all-cause outpatient visits, diagnostic testing, ED visits and hospitalizations, and a temporary increase in mortality (observed rates of 355.8 vs projected 308.8, 95% CI: 276.3-345.1). By the end of the year, outpatient visits increased (85,535.4 vs 76,620.6, 95% CI: 71,546.9-82,059.4), and most of the diagnostic test rates returned to the projected. The increase in the rate of all-cause mortality during the pandemic, compared to pre-pandemic, was greater during months with the lower frequency of diagnostic tests than months with higher frequency (interaction p-values <.0001). CONCLUSION: We described the impact of the pandemic on healthcare utilization and mortality in adults with epilepsy during the first year. We demonstrated that access to relevant diagnostic testing is likely important for this population while planning restrictions on non-urgent health services.

Predictors of Readmission, for Patients with Chronic Obstructive Pulmonary Disease (COPD) - A Systematic Review.

Introduction: Chronic obstructive pulmonary disease (COPD) is the third-leading cause of death globally and is responsible for over 3 million deaths annually. One of the factors contributing to the significant healthcare burden for these patients is readmission. The aim of this review is to describe significant predictors and prediction scores for all-cause and COPD-related readmission among patients with COPD. Methods: A search was conducted in Ovid MEDLINE, Ovid Embase, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials, from database inception to June 7, 2022. Studies were included if they reported on patients at least 40 years old with COPD, readmission data within 1 year, and predictors of readmission. Study quality was assessed. Significant predictors of readmission and the degree of significance, as noted by the p-value, were extracted for each study. This review was registered on PROSPERO (CRD42022337035). Results: In total, 242 articles reporting on 16,471,096 patients were included. There was a low risk of bias across the literature. Of these, 153 studies were observational, reporting on predictors; 57 studies were observational studies reporting on interventions; and 32 were randomized controlled trials of interventions. Sixty-four significant predictors for all-cause readmission and 23 for COPD-related readmission were reported across the literature. Significant predictors included 1) pre-admission patient characteristics, such as male sex, prior hospitalization, poor performance status, number and type of comorbidities, and use of long-term oxygen; 2) hospitalization details, such as length of stay, use of corticosteroids, and use of ventilatory support; 3) results of investigations, including anemia, lower FEV1, and higher eosinophil count; and 4) discharge characteristics, including use of home oxygen and discharge to long-term care or a skilled nursing facility. Conclusion: The findings from this review may enable better predictive modeling and can be used by clinicians to better inform their clinical gestalt of readmission risk.

Opening the digital front door for individuals using long-term in-home ventilation (LIVE) during a pandemic- implementation, feasibility and acceptability.

Background: The COVID-19 pandemic led to an unprecedented need for virtual healthcare that was safe, acceptable and feasible to deliver. In May 2020, we launched the Long-term In-Home Ventilator Engagement (LIVE) program for ventilator assisted individuals using ventilators hosted on an e-platform in Ontario, Canada. Objectives: To assess the acceptability, appropriateness, feasibility and usability of the LIVE program reported by patients, family caregivers, and healthcare providers (HCP). Design and Methods: We conducted a cross-sectional study. We provided HCPs participating in the LIVE program anonymized questionnaires (Acceptability of Intervention Measure (AIM), Intervention Appropriateness Measure (IAM), Feasibility of Intervention Measure (FIM), and mHealth App Usability (MAUQ). Patients and family caregivers completed the AIM and MAUQ. Questionnaires were administered via an e-platform. Results: We recruited 105/251 (42%) patients and family caregivers and 42/48 (87.5%) HCPs. Patients and caregivers rated a mean (SD) overall AIM score of 4.3 (0.7) (maximum score 5; higher scores indicate greater acceptability) and a mean (SD) overall MAUQ score of 5.8 (1.5) (maximum score 7; higher scores indicate greater useability). HCPs rated a mean (SD) overall AIM score of 4.3 (0.7), IAM score of 4.3 (0.8), FIM score of 4.2 (0.7) and overall MAUQ score of 5.6 ± 1.5. There were no differences in AIM ((4.3 (0.7) vs 4.3 (0.8), p = 1) or MAUQ (5.8 (1.5) vs 5.6 (1.5), p = 0.5) scores between patients/ family caregivers and HCPs. Interpretation: This study suggests that the LIVE program was acceptable, appropriate, feasible, and usable from the perspective of patients, family caregivers and HCPs.

Predicting New-onset Exertional and Resting Hypoxemia in Fibrotic Interstitial Lung Disease.

Rationale: Hypoxemia in fibrotic interstitial lung disease (ILD) indicates disease progression and is of prognostic significance. The onset of hypoxemia signifies disease progression and predicts mortality in fibrotic ILD. Accurately predicting new-onset exertional and resting hypoxemia prompts appropriate patient discussion and timely consideration of home oxygen. Objectives: We derived and externally validated a risk prediction tool for both new-onset exertional and new-onset resting hypoxemia. Methods: This study used ILD registries from Canada for the derivation cohort and from Australia and the United States for the validation cohort. New-onset exertional and resting hypoxemia were defined as nadir oxyhemoglobin saturation < 88% during 6-minute-walk tests, resting oxyhemoglobin saturation < 88%, or the initiation of ambulatory or continuous oxygen. Candidate predictors included patient demographics, ILD subtypes, and pulmonary function. Time-varying Cox regression was used to identify the top-performing prediction model according to Akaike information criterion and clinical usability. Model performance was assessed using Harrell's C-index and goodness-of-fit (GoF) likelihood ratio test. A categorized risk prediction tool was developed. Results: The best-performing prediction model for both new-onset exertional and new-onset resting hypoxemia included age, body mass index, a diagnosis of idiopathic pulmonary fibrosis, and percent predicted forced vital capacity and diffusing capacity of carbon monoxide. The risk prediction tool exhibited good performance for exertional hypoxemia (C-index, 0.70; GoF, P = 0.85) and resting hypoxemia (C-index, 0.77; GoF, P = 0.27) in the derivation cohort, with similar performance in the validation cohort except calibration for resting hypoxemia (GoF, P = 0.001). Conclusions: This clinically applicable risk prediction tool predicted new-onset exertional and resting hypoxemia at 6 months in the derivation cohort and a diverse validation cohort. Suboptimal GoF in the validation cohort likely reflected overestimation of hypoxemia risk and indicated that the model is not flawed because of underestimation of hypoxemia.

Palliative Care Among Lung Cancer Patients With and Without COPD: A Population-Based Cohort Study.

CONTEXT: Lung cancer patients with chronic obstructive pulmonary disease (COPD) may have greater palliative care needs due to poor prognosis and symptom burden. OBJECTIVES: We sought to compare the provision of timely palliative care and symptom burden by COPD status. METHODS: We performed a retrospective, population-based cohort study of individuals diagnosed with lung cancer in Ontario, Canada (2009-2019) using health administrative databases and cancer registries. The impact of COPD on the probability of receiving palliative care was determined accounting for dying as a competing event, overall and stratified by stage. The provision of palliative care for patients with severe symptoms (Edmonton Symptom Assessment Scale score ≥ 7), location of the first palliative care visit and symptom severity were compared by COPD status. RESULTS: A total of 74,993 patients were included in the study (48% of patients had available symptom data). At the time of lung cancer diagnosis, 50% of patients had COPD. Stage I-III patients with COPD were more likely to receive palliative care (adjusted Hazard Ratio (HR)s: 1.05-1.31) with no difference for stage IV (1.02, 95% CI: 1.00-1.04). Despite having severe symptoms, very few patients with early-stage disease received palliative care (Stage I: COPD-23% vs. no COPD-18%, SMD = 0.12). Most patients (84%) reported severe symptoms and COPD worsened symptom burden, especially among early-stage patients. CONCLUSION: COPD impacts the receipt of palliative care and symptom burden for patients with early-stage lung cancer. Many patients with severe symptoms did not receive palliative care, suggesting unmet needs among this vulnerable population.

Development of Multivariable Prediction Models for the Identification of Patients Admitted to Hospital with an Exacerbation of COPD and the Prediction of Risk of Readmission: A Retrospective Cohort Study using Electronic Medical Record Data.

BACKGROUND: Approximately 20% of patients who are discharged from hospital for an acute exacerbation of COPD (AECOPD) are readmitted within 30 days. To reduce this, it is important both to identify all individuals admitted with AECOPD and to predict those who are at higher risk for readmission. OBJECTIVES: To develop two clinical prediction models using data available in electronic medical records: 1) identifying patients admitted with AECOPD and 2) predicting 30-day readmission in patients discharged after AECOPD. METHODS: Two datasets were created using all admissions to General Internal Medicine from 2012 to 2018 at two hospitals: one cohort to identify AECOPD and a second cohort to predict 30-day readmissions. We fit and internally validated models with four algorithms. RESULTS: Of the 64,609 admissions, 3,620 (5.6%) were diagnosed with an AECOPD. Of those discharged, 518 (15.4%) had a readmission to hospital within 30 days. For identification of patients with a diagnosis of an AECOPD, the top-performing models were LASSO and a four-variable regression model that consisted of specific medications ordered within the first 72 hours of admission. For 30-day readmission prediction, a two-variable regression model was the top performing model consisting of number of COPD admissions in the previous year and the number of non-COPD admissions in the previous year. CONCLUSION: We generated clinical prediction models to identify AECOPDs during hospitalization and to predict 30-day readmissions after an acute exacerbation from a dataset derived from available EMR data. Further work is needed to improve and externally validate these models.

Association between COPD and Stage of Lung Cancer Diagnosis: A Population-Based Study.

Chronic obstructive pulmonary disease (COPD) is associated with an increased risk of lung cancer; however, the association between COPD and stage of lung cancer diagnosis is unclear. We conducted a population-based cross-sectional analysis of lung cancer patients (2008-2020) in Ontario, Canada. Using estimated propensity scores and inverse probability weighting, logistic regression models were developed to assess the association between COPD and lung cancer stage at diagnosis (early: I/II, advanced: III/IV), accounting for prior chest imaging. We further examined associations in subgroups with previously diagnosed and undiagnosed COPD. Over half (55%) of all lung cancer patients in Ontario had coexisting COPD (previously diagnosed: 45%, undiagnosed at time of cancer diagnosis: 10%). Compared to people without COPD, people with COPD had 30% lower odds of being diagnosed with lung cancer in the advanced stages (OR = 0.70, 95% CI: 0.68 to 0.72). Prior chest imaging only slightly attenuated this association (OR = 0.77, 95% CI: 0.75 to 0.80). The association with lower odds of advanced-stage diagnosis remained, regardless of whether COPD was previously diagnosed (OR = 0.68, 95% CI: 0.66 to 0.70) or undiagnosed (OR = 0.77, 95% CI: 0.73 to 0.82). Although most lung cancers are detected in the advanced stages, underlying COPD was associated with early-stage detection. Lung cancer diagnostics may benefit from enhanced partnership with COPD healthcare providers.

Quantifying COPD as a risk factor for cardiac disease in a primary prevention cohort.

BACKGROUND: Despite COPD being a risk factor for cardiovascular disease (CVD) and knowing that risk stratification for CVD primary prevention is important, little is known about the real-world risk of CVD among people with COPD with no history of CVD. This knowledge would inform CVD management for people with COPD. The current study aimed to examine the risk of major adverse cardiovascular events (MACE) (including acute myocardial infarction, stroke or cardiovascular death) in a large, complete real-world population with COPD without previous CVD. METHODS: We conducted a retrospective population cohort study using health administrative, medication, laboratory, electronic medical record and other data from Ontario, Canada. People without a history of CVD with and without physician-diagnosed COPD were followed between 2008 and 2016, and cardiac risk factors and comorbidities compared. Sequential cause-specific hazard models adjusting for these factors determined the risk of MACE in people with COPD. RESULTS: Among ∼5.8 million individuals in Ontario aged ≥40 years without CVD, 152 125 had COPD. After adjustment for cardiovascular risk factors, comorbidities and other variables, the rate of MACE was 25% higher in persons with COPD compared with those without COPD (hazard ratio 1.25, 95% CI 1.23-1.27). CONCLUSIONS: In a large real-world population without CVD, people with physician-diagnosed COPD were 25% more likely to have a major CVD event, after adjustment for CVD risk and other factors. This rate is comparable to the rate in people with diabetes and calls for more aggressive CVD primary prevention in the COPD population.

Treatment of rheumatoid arthritis-associated interstitial lung disease in a multi-center registry cohort.

Background: Rheumatoid arthritis-associated interstitial lung disease (RA-ILD) is challenging to manage, with a paucity of robust data to guide treatment. Our aim was to characterize the pharmacologic treatment of RA-ILD utilizing a retrospective design in a national multi-center prospective cohort, and to identify associations between treatment and change in lung function and survival. Methods: Patients with RA-ILD and a radiological pattern of non-specific interstitial pneumonia (NSIP) or usual interstitial pneumonia (UIP) were included. Unadjusted and adjusted linear mixed models and Cox proportional hazards models were used to compare lung function change and risk of death or lung transplant by radiologic patterns and treatment. Results: Of 161 patients with RA-ILD, UIP pattern was more common than NSIP (55.9% vs. 44.1%). Only 44/161 (27%) patients were treated over median follow-up of 4 years with medication choice appearing unrelated to patient-specific variables. Decline in forced vital capacity (FVC) was not associated with treatment. Patients with NSIP had lower risk of death or transplant, compared to UIP (P=0.0042). In patients with NSIP, there was no difference in time to death or transplant comparing treated to untreated in adjusted models [hazard ratio (HR) =0.73; 95% confidence interval (CI): 0.15-3.62; P=0.70]. Similarly, in patients with UIP, there was no difference in time to death or lung transplant between treated and untreated in adjusted models (HR =1.06; 95% CI: 0.49-2.28; P=0.89). Conclusions: Treatment of RA-ILD is heterogeneous, with most patients in this cohort not receiving treatment. Patients with UIP had worse outcomes compared to NSIP, similar to other cohorts. Randomized clinical trials are needed to inform pharmacologic therapy in this patient population.

Rheumatoid arthritis associated interstitial lung disease: Trends in epidemiology and mortality in Ontario from 2000 to 2018.

BACKGROUND: The epidemiology and mortality of rheumatoid arthritis related interstitial lung disease (RA-ILD) have not been described in Canada. Our aim was to describe recent trends in RA-ILD prevalence, incidence, and mortality in Ontario, Canada. METHODS: This was a retrospective population-based study using repeated cross-sections from 2000 to 2018. We estimated annual age- and sex-standardized rates for RA-ILD prevalence, incidence and mortality. RESULTS: Among 184,400 RA patients identified between 2000 and 2018, 5722 (3.1%) were diagnosed with RA-ILD. Most RA-ILD patients were women (63.9%) and ≥60 years old (76.9%) at the time of RA-ILD diagnosis. RA-ILD incidence rose from 1.6 (95% confidence interval (CI) 1.3-2.0) to 3.3 (95% CI 3.0-3.6) per 1000 RA patients (204% relative increase, p < 0.0001) during this time. RA-ILD incidence increased in both sexes and all age groups over time. The cumulative prevalence of RA-ILD increased from 8.4 (95% CI 7.6-9.2) to 21.1 (95% CI 20.3-21.8) per 1000 RA patients (250% relative increase, p < 0.0001), increasing in both sexes and all age groups. All-cause and RA-ILD related mortality declined in patients with RA-ILD over time [55.1% relative reduction, (p < 0.0001) and 70.9% relative reduction, (p < 0.0001), respectively]. In RA-ILD patients, RA-ILD contributed to the cause of death in approximately 29% of cases. Men and older patients had higher all-cause and RA-ILD related mortality. CONCLUSION: In a large, diverse Canadian population, the incidence and prevalence of RA-ILD are increasing. RA-ILD related mortality is declining, but remains an important cause of death in this population.