Pharmerit North America LLC, Bethesda, MD, USA.
J Med Econ. 2011;14(2):227-37. doi: 10.3111/13696998.2011.564246. Epub 2011 Mar 9.
Invasive aspergillosis (IA) is reported increasingly in non-traditional hosts, typically patients with chronic obstructive pulmonary disease (COPD). Objectives were to describe the excess burden of IA in COPD, including mortality, resource utilization, and costs, as well as to examine the impact of initial antifungal selection on clinical and economic outcomes.
This retrospective cohort study used national data from 2005 to 2008, from the Premier Perspective hospital database. IA was identified using proxy ICD-9 codes based on published algorithms. The COPD + IA patient cohort was analyzed using descriptive statistics. Excess resource utilization was analyzed by matching cases (COPD + IA) and controls (COPD patients without aspergillosis) on demographic and clinical variables. Multivariate analyses were used to assess the impact of initial antifungal drug selection on outcomes in COPD + IA.
In total, 475 COPD + IA patients were identified (mean age 69 years, 50% male, 76% Caucasian). COPD + IA cases had significantly higher costs, length of stay, intensive care unit (ICU) stay, and mortality compared to COPD controls (all p < 0.01). On average, antifungal therapy was initiated on hospital day 6, with mean length of therapy 15 days, and one-third of patients were in the ICU when antifungal treatment was initiated. Most commonly used antifungals were voriconazole, fluconazole, and caspofungin. Patients receiving fluconazole as the initial antifungal, an agent inactive against moulds, had almost two times greater mortality (p = 0.016), two additional hospital days (p = 0.002), and 25% greater costs (p = 0.007), compared to patients receiving voriconazole first-line. Findings were consistent in sub-analyses including ICU patients.
'Invasive' form of aspergillosis was identified using proxy ICD-9 codes based on published literature. Additional limitations stem from the study's non-randomized, retrospective design that is typical with any database analyses.
COPD + IA patients had significantly higher mortality, resource utilization, and costs versus COPD controls. Treatment with an agent active against Aspergillus was associated with better survival and reduced economic burden, therefore this potential etiology of pneumonia should be considered when contemplating antifungal therapy in COPD patients.
侵袭性曲霉菌病（IA）在非传统宿主中越来越常见，通常是慢性阻塞性肺疾病（COPD）患者。本研究的目的是描述 COPD 患者中曲霉菌病的额外负担，包括死亡率、资源利用和成本，以及研究初始抗真菌药物选择对临床和经济结局的影响。
这是一项回顾性队列研究，使用了来自 2005 年至 2008 年 Premier Perspective 医院数据库的全国性数据。IA 是通过基于已发表算法的代理 ICD-9 代码来识别的。对 COPD+IA 患者队列进行描述性统计分析。通过在人口统计学和临床变量上匹配病例（COPD+IA）和对照（无曲霉菌病的 COPD 患者）来分析资源利用的差异。使用多变量分析评估初始抗真菌药物选择对 COPD+IA 患者结局的影响。
共确定了 475 例 COPD+IA 患者（平均年龄 69 岁，50%为男性，76%为白种人）。与 COPD 对照相比，COPD+IA 患者的费用、住院时间、重症监护病房（ICU）住院时间和死亡率均显著更高（均 P<0.01）。平均而言，抗真菌治疗在住院第 6 天开始，治疗时间平均为 15 天，三分之一的患者在开始抗真菌治疗时在 ICU。最常用的抗真菌药物为伏立康唑、氟康唑和卡泊芬净。接受氟康唑作为初始抗真菌药物（一种对霉菌无效的药物）的患者死亡率几乎高出两倍（P=0.016），住院天数增加两天（P=0.002），费用增加 25%（P=0.007），与接受伏立康唑一线治疗的患者相比。在包括 ICU 患者的亚分析中，结果一致。
曲霉菌病的“侵袭性”形式是通过基于已发表文献的代理 ICD-9 代码来识别的。由于该研究是典型的数据库分析，具有非随机、回顾性设计，因此还存在其他局限性。
与 COPD 对照相比，COPD+IA 患者的死亡率、资源利用和成本均显著更高。使用对曲霉菌有效的药物治疗与更好的生存和降低经济负担相关，因此在考虑 COPD 患者的抗真菌治疗时，应考虑肺炎的这种潜在病因。
