Introduction: Corticosteroids remain one of the pillars of treatment for acute exacerbations of chronic obstructive pulmonary disease (AECOPD). Prior studies have shown the precipitation of adrenal insufficiency (AI) due to suppression of the hypothalamic-pituitary-adrenal axis but impacts on hospital outcomes and healthcare utilization has not been studied extensively. The aim of this project is to characterize outcomes of patients being treated for AECOPD in the presence of AI. We hypothesize that patients with AI would experience higher in-patient mortality, longer length of stay (LOS), and higher total charges.
Methods: We performed a retrospective cohort study using the National Inpatient Sample (NIS) from 2016 to 2022, extracting patients with AECOPD (International Classification of Diseases, Tenth Revision code J44.1). Groups were assigned based on presence of AI, which also includes patients with previous diagnosis of AI. Primary outcomes included in-hospital mortality, LOS, and total charges. Propensity score matching was done with age, gender, and the Elixhauser index calculated with Van Walraven algorithm. Analyses were also stratified by race.
Results: After matching, 4,250 total patients (2,125 with AI and 2,125 controls) were included in the study. The presence of adrenal insufficiency was not associated with increased in-hospital mortality (OR 1.07, 95% CI 0.81-1.42, p = 0.618), bur results showed significant associations with longer LOS (0.83 days on average, 95% CI 0.30-1.37, p = 0.002) and higher hospital costs (73.5% increase, 95% CI 0.495–0.607; p < 0.001). In race-stratified models the largest increases in LOS were seen in Blacks (3.25 days, 95% CI 1.00–5.51, p=0.005) and Hispanics (5.58 days, 95% CI 2.74–8.42, p< 0.001). These populations also witnessed the largest increase in cost (71.2% in Black, 229% in Hispanic).
Conclusions: Although having AI did not significantly increase mortality, it was associated with longer LOS and higher costs. This suggests that adrenal suppression from high dose steroids given in AECOPD complicates the hospital course, requiring more resource utilization. This burden was further shown to be disproportionate in Black and Hispanic populations. Future studies may explore alternative treatments or dose adjustments, especially in vulnerable populations.
