Missed opportunities in the therapeutic patterns of chronic obstructive pulmonary disease: a real-world Italian study on the impact of severe exacerbation on mortality and hospital re-admission

Background and Objectives: Patients experiencing severe exacerbation (SE) of chronic obstructive pulmonary disease (COPD) face high re-hospitalization and mortality rates. Knowing their impact on health services is crucial for making decisions and improving the care pathway for these patients. To describe mortality, re-hospitalizations and therapeutic patterns of patients experiencing SE, this study used real-world Italian administrative data and examined pre- and post-SE treatment patterns. Methods: From an Italian administrative database (4.6 million inhabitants), patients with COPD in 2022 were identified, and those experiencing SE requiring hospitalization were described in terms of demographics, comorbidities, 12-month mortality and re-hospitalization rates, and therapeutic patterns during 12 months pre- and post-SE. Treatment patterns included dispensations of single-inhaler (SI, i.e., fixed-dose combination) triple therapy (TT), multiple-inhaler (MI, i.e., open combination) TT, dual therapy (DT; based on combinations between inhaled corticosteroid/long-acting beta-agonist/muscarinic antagonist), other respiratory treatment strategies, and no treatment. Results: Among 81,571 patients with COPD (32.1 per 1000 inhabitants aged ≥ 45 years), patients experiencing SE were 6.2% (5080 patients with COPD): mean age was 77 years, 63.4% (3220 patients with SE) were male and 68.2% (3467 patients with SE) had ≥ 3 comorbidities. Mean in-hospital length of stay was 11.9 days. One-year mortality rate was 25.6% (1302 patients with SE), mainly within the first month, 76.0% (989 deaths) of which occurred in hospital. Among 12-month analysable patients (3778), the 12-month re-hospitalization rate was 20.1% (761 patients with SE and alive) occurring, on average, at 155 days (16.4% within the first month). Pre/post SE, single-inhaler triple therapy (SI-TT) and multiple-inhaler triple therapy (MI-TT) increased from 1.4 to 23.4% and from 1.2 to 6.3% patients, respectively; DT, other strategies, and no treatment reduced from 24.5 to 22.5%, 35.7 to 23.8% and 37.1 to 24.0%, respectively. On average, TT was initiated at ≥ 31 days post-SE. Mean time to TT initiation was approximately 31–42 days depending on prior therapy, although most patients initiated TT within the first 30 days. Conclusion: A substantial proportion of patients experiencing SE of COPD were re-hospitalised or remained inadequately treated or untreated, despite a high mortality rate. These findings underscore the necessity for a more appropriate and prompt therapeutic intervention.