Mortality, seasonal variation, and susceptibility to acute exacerbation of COPD in the pandemic year: a nationwide population study

Abstract

Background: Previous studies have suggested that the coronavirus disease 2019 (COVID-19) pandemic was associated with a decreased rate of acute exacerbation of chronic obstructive pulmonary disease (AECOPD). Data on how the COVID-19 pandemic has influenced mortality, seasonality of, and susceptibility to AECOPD in the chronic obstructive pulmonary disease (COPD) population is scarce.

Methods: We conducted a national population-based retrospective study using data from the Health Insurance Institute of Slovenia from 2015 to February 2021, with 2015-2019 as the reference. We extracted patient and healthcare data for AECOPD, dividing AECOPD into severe, resulting in hospitalisation, and moderate, requiring outpatient care. The national COPD population was generated based on dispensed prescriptions of inhalation therapies, and moderate AECOPD events were analysed based on dispensed AECOPD medications. We extracted data on all-cause and non-COVID mortality.

Results: The numbers of severe and moderate AECOPD were reduced by 48% and 34%, respectively, in 2020. In the pandemic year, the seasonality of AECOPD was reversed, with a 1.5-fold higher number of severe AECOPD in summer compared to winter. The proportion of frequent exacerbators (⩾2 AECOPD hospitalisations per year) was reduced by 9% in 2020, with a 30% reduction in repeated severe AECOPD in frequent exacerbators and a 34% reduction in persistent frequent exacerbators (⩾2 AECOPD hospitalisations per year for 2 consecutive years) from 2019. The risk of two or more moderate AECOPD decreased by 43% in 2020. In the multivariate model, pandemic year follow-up was the only independent factor associated with a decreased risk for severe AECOPD (hazard ratio [HR]: 0.71; 95% confidence interval [CI]: 0.61-0.84; p < 0.0001). In 2020, non-COVID mortality decreased (-15%) and no excessive mortality was observed in the COPD population.

Conclusion: In the pandemic year, we found decreased susceptibility to AECOPD across severity spectrum of COPD, reversed seasonal distribution of severe AECOPD and decreased non-COVID mortality in the COPD population.

Keywords: COPD; COVID-19 pandemic; acute exacerbation; seasonality.

Figure 1.

Relative changes in the pandemic year relative to the 2015–2019 average. (a) hospitalizations across diseases and (b) selected indicators for COPD hospitalizations. H, hospitalizations; LOS, length of stay. ^a Negative exponential trend, average annual growth rate: −10.3%, R2 = 0.978. ^b Positive exponential trend, average annual growth rate: 14.1%, R2 = 0.8321. ^c Negative exponential trend; average annual growth rate: −5.3%; R2 = 0.5648.

Figure 2.

Comparison of the seasonality of AECOPD hospitalizations in the pandemic year vs previous years.

Figure 3.

Cumulative incidence of COPD rehospitalizations and all-cause mortality (competing risk) according to the follow-up period.

Figure 4.

Mortality rate in the COPD population in pandemic vs pre-pandemic years: (a) monthly mortality rate over 12 months and (b) excessive mortality in the COPD population compared to excessive mortality in the general population.