Clinical guidelines urge usage of exacerbation past successful choosing therapies to foretell the hazard for chronic obstructive pulmonary illness exacerbations, but an investigation of information from 3 antithetic objective studies has recovered that exacerbation past unsocial is not the astir close risk-prediction instrumentality — and that it whitethorn adjacent origin harm successful immoderate situations.
"Our results contiguous a cautionary communicative for the imaginable hazard of harm to patients erstwhile naively applying hazard stratification algorithms crossed antithetic objective settings," pb writer Joseph Khoa Ho, PharmD, a master's campaigner successful pharmaceutical sciences astatine the University of British Columbia successful Vancouver, Canada, told Medscape Medical News.
"We amusement that risk-prediction models person amended accuracy than exacerbation past unsocial for predicting the aboriginal hazard of COPD exacerbations," helium said. "However, the prediction models required re-evaluation and setting-specific recalibration successful bid to output higher objective utility."
The study, known arsenic IMPACT, analyzed 3 trials that enrolled 4107 patients astatine varying levels of mean oregon terrible exacerbation risks: the placebo limb of the Study to Understand Mortality and Morbidity successful COPD (SUMMIT; N = 2421); the Long-term Oxygen Treatment Trial (LOTT; N = 595); and the placebo limb of the Towards a Revolution successful COPD Health proceedings (TORCH; N = 1091). The exacerbation risks were low, medium, and precocious successful the 3 respective trials.
The study, published online this period successful the diary CHEST, compared the show of 3 risk-stratification algorithms:
Exacerbation history
The exemplary that Loes C.M. Bertens, PhD, and colleagues successful the Netherlands developed successful 2013
The latest mentation of the Acute COPD Exacerbation Prediction Tool, known arsenic ACCEPT
Results of the Analysis
The survey utilized country nether the curve (AUC), a method of evaluating effectiveness oregon efficiency, to comparison show of the prediction algorithms. ACCEPT outperformed exacerbation past and the Bertens algorithm successful each the LOTT (medium risk) and TORCH (high risk) samples, some of which were statistically significant. In SUMMIT (low risk), Bertens and ACCEPT outperformed exacerbation history, which was statistically significant.
The AUC for exacerbation past unsocial successful predicting aboriginal exacerbations successful SUMMIT, LOTT, and TORCH was 0.59 (95% CI, 0.57 - 0.61), 0.63 (95% CI, 0.59 - 0.67), and 0.65 (95% CI, 0.63 - 0.68), respectively. Bertens had a higher AUC compared with exacerbation past unsocial successful SUMMIT (increase of 0.10, P < .001) and TORCH (increase of 0.05, P < .001), but not successful LOTT (increase of 0.01, P = .84).
ACCEPT had higher AUC compared with exacerbation past unsocial successful each survey samples, by 0.08 (P < .001), 0.07 (P = .001) and 0.10 (P < .001), respectively. Compared with Bertens, ACCEPT had higher AUC by 0.06 (P = .001) successful LOTT and 0.05 (P < .001) successful TORCH, whereas the AUCs were not antithetic successful SUMMIT (change of -0.02, P = .16).
Study Rationale
Senior writer Mohsen Sadatsafavi, MD, PhD, subordinate prof of pharmaceutical sciences astatine the University of British Columbia, told Medscape Medical News that this survey was inspired by a study successful cardiology earlier successful 2022 that recovered that the show of the multitude of risk-prediction tools utilized to measure cardiovascular illness hazard tin alteration wide if they're not calibrated for caller diligent populations.
"The main uncovering was that exacerbation past unsocial tin beryllium harmful adjacent if it is applied astatine antithetic hazard levels," Sadatsafavi said of the IMPACT study. "No algorithm could beryllium universally applicable, but exacerbation past has a precise precocious accidental of being worse than not doing immoderate hazard stratification astatine each and simply giving medicine to each patients."
Exacerbation past was considered harmful due to the fact that it generated a little nett payment than the either Bertens oregon ACCEPT, the IMPACT survey found.
The payment of the 2 risk-prediction tools is that they tin beryllium recalibrated, Sadatsafavi said. "You don't person that luxury with exacerbation past due to the fact that it's conscionable a fixed affirmative oregon antagonistic history," helium said. "We request to beryllium rather cognizant of the quality successful lung attacks successful antithetic populations and the information that exacerbation past has precise antithetic show successful antithetic groups and mightiness beryllium harmful erstwhile applied successful definite populations. We suggest the usage of the risk-stratification tools arsenic a amended due statistical model."
Expert Comment
"As the authors constituent out, existent guidelines for COPD absorption urge preventive exacerbation therapy considering the patient's exacerbation history," Mary Jo S. Farmer, MD, PhD, adjunct prof astatine the University of Massachusetts Chan Medical School–Baystate successful Worcester, said via email. "However, this strategy has demonstrated harm successful immoderate situations."
She noted that the multivariable prediction models were much close than exacerbation past unsocial for predicting 12-month hazard of moderate/severe COPD exacerbations, but that nary algorithm was superior successful objective inferior crossed each samples.
"The authors reason that the highest accuracy of a hazard prediction exemplary tin beryllium achieved erstwhile the exemplary is recalibrated based connected the baseline exacerbation hazard of the survey colonisation successful question," Farmer added.
The survey received backing from the Canadian Institutes of Health Research. Ho, Sadatsafavi, and Farmer study nary applicable fiscal relationships.
CHEST. Published online December 8, 2022. Abstract
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