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Rationale: Lung transplantation is an accepted and increasingly employed treatment for advanced lung diseases, but the anticipated survival benefit of lung transplantation is poorly understood., Objectives: To determine whether and for which patients lung transplantation confers a survival benefit in the modern era of U.S. lung allocation., Methods: Data on 13,040 adults listed for lung transplantation between May 2005 and September 2011 were obtained from the United Network for Organ Sharing. A structural nested accelerated failure time model was used to model the survival benefit of lung transplantation over time. The effects of patient, donor, and transplant center characteristics on the relative survival benefit of transplantation were examined., Measurements and Main Results: Overall, 73.8% of transplant recipients were predicted to achieve a 2-year survival benefit with lung transplantation. The survival benefit of transplantation varied by native disease group (P = 0.062), with 2-year expected benefit in 39.2 and 98.9% of transplants occurring in those with obstructive lung disease and cystic fibrosis, respectively, and by lung allocation score at the time of transplantation (P < 0.001), with net 2-year benefit in only 6.8% of transplants occurring for lung allocation score less than 32.5 and in 99.9% of transplants for lung allocation score exceeding 40., Conclusions: A majority of adults undergoing transplantation experience a survival benefit, with the greatest potential benefit in those with higher lung allocation scores or restrictive native lung disease or cystic fibrosis. These results provide novel information to assess the expected benefit of lung transplantation at an individual level and to enhance lung allocation policy.

Rationale: Older patients are at high risk of death and rehospitalization after hospitalizations for acute exacerbations of chronic obstructive pulmonary disease (AE-COPD). Emergency department visits comprise a substantial portion of acute care encounters in this patient population. The risks of mortality and repeat acute care encounters, including both hospital readmission and repeat emergency department visits, after AE-COPD among older adults are not well understood., Objectives: To examine early and long-term rates of death and repeat acute care encounters after hospitalization or emergency department visit for AE-COPD in Medicare fee-for-service beneficiaries and to identify patient characteristics, including medical comorbid conditions, associated with these outcomes., Methods: A retrospective analysis was conducted using a nationally representative 5% sample of Medicare fee-for-service claims data from the U.S. Centers for Medicare and Medicaid Services to identify Medicare beneficiaries 65 years or older who had an acute care episode for an AE-COPD between January 1, 2006, and December 31, 2010 (n = 52,741). Outcomes of interest were all-cause mortality, repeat acute care encounters for any cause, and repeat acute care encounters for AE-COPD at 30 days, 1 year, and 3 years., Measurements and Main Results: Acute care encounters, including hospitalizations and emergency department visits for AE-COPD, were associated with substantial subsequent mortality risk, with 4.6, 24.4, and 48.2% dying by 30 days, 1 year, and 3 years, respectively. The risk of repeat hospitalization or emergency department visit was similarly high, with 1 in 4 patients having a repeat acute care encounter within 30 days of discharge, increasing to 9 in 10 in the next 3 years. Several comorbid conditions and other patient factors, including heart failure, malnutrition, dual eligibility for Medicare and Medicaid, and prior supplemental oxygen use, were independently associated with increased risk of repeat acute care encounter., Conclusions: Repeat hospitalizations and emergency department visits and death are common in older fee-for-service Medicare beneficiaries seen in acute care for AE-COPD. Our results suggest that addressing important comorbid conditions, such as heart failure or malnutrition, and targeting resources to oxygen-dependent or dual Medicare- and Medicaid-eligible patients may help modify these outcomes.

Rationale: The 2011 combined Global Initiative for Chronic Obstructive Lung Disease (GOLD) assessment incorporates symptoms, exacerbation history, and spirometry in discriminating risk of exacerbations in patients with chronic obstructive pulmonary disease (COPD). Six-minute-walk distance (6MWD) and accelerometry also have been used to assess disease severity in COPD. The association between these measures and the risks of hospitalization and mortality in the context of GOLD 2011 is unknown., Objectives: To describe changes in exercise tolerance and physical activity over time in patients with COPD and to test the hypothesis that lower baseline 6MWD or accelerometry step count is associated with increased risk of COPD-related hospitalization or all-cause mortality, independent of GOLD 2011 group., Methods: Physical function and medical outcomes were prospectively assessed in 326 patients with moderate to severe COPD in INSPIRE-II, a randomized controlled trial of a coping skills training intervention. Cox models were used to determine if GOLD 2011 group, 6MWD, or accelerometry steps were associated with risk of COPD-related hospitalization or all-cause mortality., Measurements and Main Results: Physical function declined over time in GOLD group D but remained stable in groups A, B, and C. GOLD classification was associated with time to death or first COPD-related hospitalization. Baseline 6MWD was more strongly associated with time to death or first COPD-related hospitalization (hazard ratio, 0.50 [95% confidence interval, 0.34, 0.73] per 150 m, P=0.0003) than GOLD 2011 classification. A similar relationship was observed for accelerometry steps (hazard ratio, 0.80 [95% confidence interval, 0.70, 0.92] per 1,000 steps, P=0.002)., Conclusions: Exercise tolerance and daily physical activity are important predictors of hospitalization and mortality in COPD, independent of GOLD 2011 classification. Physical function may represent a modifiable risk factor that warrants increased attention as a target for interventions to improve clinically meaningful outcomes in COPD.