***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    Input: Background R and omized controlled trials , evidence -based medicine , clinical guidelines , and total quality management are some of the approaches used to render science-based health care services . The clinical pathway for hospitalized patients suffering from acute exacerbations of chronic obstructive pulmonary disease ( AE COPD ) is poorly established , although a clinical pathway is an integral part of total quality management . Aim To evaluate the outcomes of patients hospitalized with AE COPD in Japan , treated with a clinical pathway following published guidelines . Methods Prospect i ve data were collected for patients with AE COPD admitted to a general hospital over a 5-year period since 2003 . The clinical pathway was design ed to establish general rules for the entire treatment protocol . The clinical pathway indicates which treatments and interventions should be performed , and when . In this study , health care providers were required to check the clinical pathway sheets to determine the next step of treatment . Results This study analyzed 276 hospitalizations in 165 patients . The clinical pathway was interrupted and defined as a dropout in 45 cases ( 16.3 % ) . Nine patients died during hospitalization ( 3.3 % ) . Oxygen was administered in 232 hospitalizations ( 84.1 % ) .  Noninvasive positive pressure ventilation  ( NPPV ) treatment was administered in 110 hospitalizations ( 39.9 % ) . The rate of intubation in those cases where NPPV treatment had been administered was 8.2 % ( 9 cases out of 110 ) . The average length of stay ( LOS ) was 20.3 days , and the median value was 15 days . The LOS was longer than 30 days in 34 admissions ( 12.3 % ) , mainly due to complications . Conclusion AE COPD can be managed using a clinical pathway . This clinical pathway could fill the gap between guidelines and clinical practice Background : Little is known about the long-term outcomes of individuals with mild chronic obstructive pulmonary disease ( COPD ) as defined by the Global Initiative for Chronic Obstructive Lung Disease ( GOLD ) . Methods : A population cohort of 6671 r and omly selected adults without asthma was stratified into categories of modified GOLD-defined COPD ( prebronchodilator spirometry ) . Further stratification was based on the presence or absence of respiratory symptoms . After 11 years , associations between baseline categories of COPD and decline in forced expiratory volume in 1 s ( FEV1 ) , respiratory care utilisation and quality of life as measured by the SF-36 question naire were examined after controlling for age , sex , smoking and educational status . Results : At baseline , modified GOLD criteria were met by 610 ( 9.1 % ) participants , 519 ( 85.1 % ) of whom had stage 1 COPD . At follow-up , individuals with symptomatic stage 1 COPD ( n = 224 ) had a faster decline in FEV1 ( −9 ml/year ( 95 % CI −13 to −5 ) ) , increased respiratory care utilisation ( OR 1.6 ( 95 % CI 1.0 to 2.6 ) ) and a lower quality of life than asymptomatic subjects with normal lung function ( n = 3627 , reference group ) . In contrast , individuals with asymptomatic stage 1 COPD ( n = 295 ) had no significant differences in FEV1 decline ( −3 ml/year ( 95 % CI −7 to + 1 ) ) , respiratory care utilisation ( OR 1.05 ( 95 % CI 0.63 to 1.73 ) ) or quality of life scores compared with the reference group . Conclusions : In population -based studies , respiratory symptoms are of major importance for predicting long-term clinical outcomes in subjects with COPD with mild obstruction . Population studies based on spirometry only may misestimate the prevalence of clinical ly relevant COPD Background Exacerbations , a leading cause of hospitalization in patients with chronic obstructive pulmonary disease ( COPD ) , affect the quality of life and prognosis . Treatment recommendations as provided in the evidence -based guidelines are not consistently followed , partly due to absence of simplified task-oriented approach to care . In this study , we describe the development and implementation of a clinical pathway ( CP ) and evaluate its effectiveness in the management of COPD exacerbation . Methods We developed a CP and evaluated its effectiveness in a non-r and omized prospect i ve study with historical controls on patients admitted for exacerbation of COPD to Universiti Kebangsaan Malaysia Medical Centre ( UKMMC ) . Consecutive patients who were admitted between June 2009 and December 2010 were prospect ively recruited into the CP group . Non-CP historical controls were obtained from case records of patients admitted between January 2008 and January 2009 . Clinical outcomes were evaluated by comparing the length of stay ( LOS ) , complication rates , readmissions , and mortality rates . Results Ninety-five patients were recruited in the CP group and 98 patients were included in the non-CP historical group . Both groups were comparable with no significant differences in age , sex and severity of COPD ( p = 0.641 ) . For clinical outcome measures , patients in the CP group had shorter length of stay than the non-CP group ( median ( IQR ) : 5 ( 4–7 ) days versus 7 ( 7–9 ) days , p < 0.001 ) and 24.1 % less complications ( 14.7 % versus 38.8 % , p < 0.001 ) . We did not find any significant differences in readmission and mortality rates . Conclusion The implementation of CP –reduced  the length of stay and complication rates of patients hospitalized for acute exacerbation of COPD It was postulated that home hospitalisation ( HH ) of selected chronic obstructive pulmonary disease ( COPD ) exacerbations admitted at the emergency room ( ER ) could facilitate a better outcome than conventional hospitalisation . To this end , 222 COPD patients ( 3.2 % female ; 71±10 yrs ( mean±sd ) ) were r and omly assigned to HH ( n=121 ) or conventional care ( n=101 ) . During HH , integrated care was delivered by a specialised nurse with the patient 's free-phone access to the nurse ensured for an 8‐week follow-up period . Mortality ( HH : 4.1 % ; controls : 6.9 % ) and hospital readmissions ( HH : 0.24±0.57 ; controls : 0.38±0.70 ) were similar in both groups . However , at the end of the follow-up period , HH patients showed : 1 ) a lower rate of ER visits ( 0.13±0.43 versus 0.31±0.62 ) ; and 2 ) a noticeable improvement of quality of life ( Δ St George 's Respiratory Question naire ( SGRQ ) , −6.9 versus −2.4 ) . Furthermore , a higher percentage of patients had a better knowledge of the disease ( 58 % versus 27 % ) , a better self-management of their condition ( 81 % versus 48 % ) , and the patient 's satisfaction was greater . The average overall direct cost per HH patient was 62 % of the costs of conventional care , essentially due to fewer days of inpatient hospitalisation ( 1.7±2.3 versus 4.2±4.1 days ) . A comprehensive home care intervention in selected chronic obstructive pulmonary disease exacerbations appears as cost effective . The home hospitalisation intervention  generates better outcomes at lower costs than conventional care Objectives : To determine the effects of a nurse led intermediate care programme in patients who have been hospitalised with an acute exacerbation of chronic obstructive pulmonary disease ( AE COPD ) . Design : R and omised controlled trial . Setting : Community and hospital care in west London . Participants : 122 patients with COPD . Intervention : A care package incorporating initial pulmonary rehabilitation and self-management education , provision of a written , personalised COPD action plan , monthly telephone calls and 3 monthly home visits by a specialist nurse for a period of 2 years . Main outcome measure : Hospital readmission rate . Secondary outcomes : Unscheduled primary care consultations and quality of life . Results : There were no differences in hospital admission rates or in exacerbation rates between the two groups . Self-management of exacerbations was significantly different and the intervention group were more likely to be treated with oral steroids alone or oral steroids and antibiotics , and the initiators of treatment for exacerbations were statistically more likely to be the patients themselves . 12 patients in the control group died during the 2 year period , eight as a result of COPD , compared with six patients in the intervention group , of whom one died from COPD . This is a significant difference . When the numbers were adjusted to reflect the numbers still alive at 2 years , in the intervention group patients reported a total of 171 unscheduled contacts with their general practitioner ( GP ) and in the control group , 280 contacts . The number needed to treat was 0.558—ie , for every one COPD patient receiving the intervention and self-management advice , there were 1.79 fewer unscheduled contacts with the GP . Conclusions : An intermediate care package incorporating pulmonary rehabilitation , self-management education and the receipt of a written COPD action plan , together with regular nurse contact , is associated with a reduced need for unscheduled primary care consultations and a reduction in deaths due to COPD but did not affect the hospital readmission rate BACKGROUND Treatment with systemic corticosteroids for exacerbations of COPD results in improvement in clinical outcomes . On hospitalization , corticosteroids are generally administered IV . It has not been established whether oral administration is equally effective . We conducted a study to demonstrate that therapy with oral prednisolone was not inferior to therapy with IV prednisolone using a double-blind , double-dummy design . METHODS Patients hospitalized for an exacerbation of COPD were r and omized to receive 5 days of therapy with prednisolone , 60 mg IV or orally . Treatment failure , the primary outcome , was defined as death , admission to the ICU , readmission to the ICU because of COPD , or the intensification of pharmacologic therapy during a 90-day follow-up period . RESULTS A total of 435 patients were referred for a COPD exacerbation warranting hospitalization ; 107 patients were r and omized to receive IV therapy , and 103 to receive oral therapy .  Overall treatment failure within 90 days was similar , as follows : IV prednisolone , 61.7 % ; oral prednisolone , 56.3 % ( one-sided lower bound of the 95 % confidence interval [ CI ] , -5.8 % ) . There were also no differences in early ( ie , within 2 weeks ) treatment failure ( 17.8 % and 18.4 % , respectively ; one-sided lower bound of the 95 % CI , -9.4 % ) , late ( ie , after 2 weeks ) treatment failure ( 54.0 % and 47.0 % , respectively ; one-sided lower bound of the 95 % CI , -5.6 % ) , and mean ( + /- SD ) length of hospital stay ( 11.9 + /- 8.6 and 11.2 + /- 6.7 days , respectively ) . Over 1 week , clinical ly relevant improvements were found in spirometry and health-related quality of life , without significant differences between the two treatment groups . CONCLUSION Therapy with oral prednisolone is not inferior to IV treatment in the first 90 days after starting therapy . We suggest that the oral route is preferable in the treatment of COPD exacerbations . TRIAL REGISTRATION Clinical trials.gov Identifier : NCT00311961 Background Early treatment of COPD exacerbations has shown to be important . Despite a non-negligible negative impact on health related quality of life , a large proportion of these episodes is not reported ( no change in treatment ) . Little is known whether ( low burden ) strategies are able to capture these unreported exacerbations . Methods The Clinical COPD Question naire ( CCQ ) is a short question naire with great evaluative properties in measuring health status . The current explorative study evaluates the discriminative properties of weekly CCQ assessment in detecting exacerbations . Results In a multicentre prospect i ve cohort study , 121 patients , age 67.4 ± 10.5 years , FEV1 47.7 ± 18.5 % pred were followed for 6 weeks by daily diary card recording and weekly CCQ assessment . Weeks were retrospectively labeled as stable or exacerbation ( onset ) weeks using the Anthonisen symptom diary-card algorithm . Change in CCQ total scores are significantly higher in exacerbation-onset weeks , 0.35 ± 0.69 compared to -0.04 ± 0.37 in stable weeks ( p < 0.001 ) . Performance of the Δ CCQ total score discriminating between stable and exacerbation onset weeks was sufficient ( area under the ROC curve 0.75 ) . At a cut off point of 0.2 , sensitivity was 62.5 ( 50.3 - 73.4 ) , specificity 82.0 ( 79.3 - 84.4 ) , and a positive and negative predictive value of 43.5 ( 35.0 - 51.0 ) and 90.8 ( 87.8 - 93.5 ) , respectively . Using this cut off point , 22 ( out of 38 ) unreported exacerbations were detected while 39 stable patients would have been false positively ' contacted ' . Conclusions Weekly CCQ assessment is a promising , low burden method to detect unreported exacerbations . Further research is 
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It was also associated with high economic burden across all countries .
The overall , direct , and indirect costs per patient increased with an increase in symptoms , dyspnoea severity , and duration of disease .
Across countries , the annual societal costs associated with symptomatic COPD were higher among patients with comorbidities .
Conclusions Symptomatic COPD is associated with a substantial economic burden .
The HRQoL of patients with symptomatic COPD is , in general , low and influenced by dyspnoea