Adherence to long-acting inhaled medications among patients with COPD is poor, and determinants of adherence likely differ by medication class. Patient perception of clinician expertise in lung disease was the factor most highly associated with adherence to long-acting therapies.

A B S T R A C T PurposeLung cancer is the leading cause of cancer-related mortality. Intensive care unit (ICU) use among patients with cancer is increasing, but data regarding ICU outcomes for patients with lung cancer are limited. Patients and MethodsWe used the Surveillance, Epidemiology, and End Results (SEER) -Medicare registry (1992 to 2007) to conduct a retrospective cohort study of patients with lung cancer who were admitted to an ICU for reasons other than surgical resection of their tumor. We used logistic and Cox regression to evaluate associations of patient characteristics and hospital mortality and 6-month mortality, respectively. We calculated adjusted associations for mechanical ventilation receipt with hospital and 6-month mortality. ResultsOf the 49,373 patients with lung cancer admitted to an ICU for reasons other than surgical resection, 76% of patients survived the hospitalization, and 35% of patients were alive 6 months after discharge. Receipt of mechanical ventilation was associated with increased hospital mortality (adjusted odds ratio, 6.95; 95% CI, 6.89 to 7.01; P Ͻ .001), and only 15% of these patients were alive 6 months after discharge. Of all ICU patients with lung cancer, the percentage of patients who survived 6 months from discharge was 36% for patients diagnosed in 1992 and 32% for patients diagnosed in 2005, whereas it was 16% and 11% for patients who received mechanical ventilation, respectively. ConclusionMost patients with lung cancer enrolled in Medicare who are admitted to an ICU die within 6 months of admission. To improve patient-centered care, these results should guide shared decision making between patients with lung cancer and their clinicians before an ICU admission.

Background There is little data about the combined effects of COPD and obesity. We compared dyspnea, health-related quality of life (HRQoL), exacerbations, and inhaled medication use among patients who are overweight and obese to those of normal weight with COPD. Methods We performed secondary data analysis on 364 Veterans with COPD. We categorized subjects by body mass index (BMI). We assessed dyspnea using the Medical Research Council (MRC) dyspnea scale and HRQoL using the St. George's Respiratory Questionnaire. We identified treatment for an exacerbation and inhaled medication use in the past year. We used multiple logistic and linear regression models as appropriate, with adjustment for age, COPD severity, smoking status, and comorbidities. Results The majority of our population was male (n=355, 98%) and either overweight (n=115, 32%) or obese (n=138, 38%). Obese and overweight subjects had better lung function (obese: mean FEV1 55.4% ±19.9% predicted, overweight: mean FEV1 50.0% ±20.4% predicted) than normal weight subjects (mean FEV1 44.2% ±19.4% predicted), yet obese subjects reported increased dyspnea [adjusted OR of MRC score ≥2= 4.91 (95% CI 1.80, 13.39], poorer HRQoL, and were prescribed more inhaled medications than normal weight subjects. There was no difference in any outcome between overweight and normal weight patients. Conclusions Despite having less severe lung disease, obese patients reported increased dyspnea and poorer HRQoL than normal weight patients. The greater number of inhaled medications prescribed for obese patients may represent overuse. Obese patients with COPD likely need alternative strategies for symptom control in addition to those currently recommended.

Background: Elderly patients surviving community-acquired pneumonia (CAP) have subsequent increased mortality. However, little is known regarding long-term survival in younger adults or those with healthcare-associated pneumonia (HCAP). Objectives: To identify factors associated with mortality and compare long-term survival in patients hospitalized with HCAP to that of patients with CAP. Methods: We determined survival after discharge as of December 2002 in a patient cohort admitted with pneumonia between June 1994 and May 1996. We used the Cox proportional hazard model to estimate differences in survival after controlling for confounders. Results: Of the 522 patients hospitalized with pneumonia, 457 survived to discharge. One hundred sixty-four patients (36%, 95% confidence interval, CI, 31–40%) were admitted with HCAP, while 293 (64%, 95% CI 60–69%) were admitted with CAP. Of the 181 deaths in the follow-up period, 70 occurred in patients under age 65 years admitted with HCAP (53% death rate, 95% CI 44–62%). Nineteen of these deaths (27%, 95% CI 17–39%) occurred in the absence of HIV infection. In patients under the age of 65 whose only risk factor for HCAP was treatment for pneumonia or hospitalization in the previous 90 days, 4 of 13 patients (31%, 95% CI 9–61%) died. Twenty percent (95% CI 15–26%) of patients under age 65 years admitted with CAP died during the follow-up. Conclusions: Admission for HCAP, and to a lesser degree CAP, is associated with increased long-term mortality even in young patients. Future studies are warranted to identify interventions to improve survival in this population.

Communication between patients and clinicians is associated with quality of care and confidence in dealing with breathing problems, and this association may change over time. Attention to specific communication strategies may lead to improvements in the care of patients with COPD.