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Global Prevalence of Asthma-COPD Overlap (ACO) in the General Population: a Systematic Review and Meta-Analysis

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Global Prevalence of Asthma-COPD Overlap (ACO) in the General Population: a Systematic Review and Meta-Analysis Hosseini et al. Respiratory Research (2019) 20:229 https://doi.org/10.1186/s12931-019-1198-4 REVIEW Open Access Global prevalence of asthma-COPD overlap (ACO) in the general population: a systematic review and meta-analysis Mostafa Hosseini1, Amir Almasi-Hashiani2, Mahdi Sepidarkish3 and Saman Maroufizadeh4* Abstract Background: Asthma-COPD overlap (ACO) is a term that encompasses patients with features of both asthma and COPD. To date, the global prevalence of ACO in the general population remains unknown. The objective of this study was to estimate the prevalence of ACO in the general population using a systematic review and meta- analysis. Methods: A systematic search of ISI Web of Knowledge, MEDLINE/PubMed, and Scopus was performed up to May 2019 to identify studies reporting the prevalence of ACO. Reference lists from identified studies and relevant review articles were also searched. Eligibility criteria were studies reporting the prevalence of ACO, performed in general population, and published in English language. Pooled prevalence of ACO with 95% confidence interval (CI) was calculated using random effects Meta-analysis. Results: A total of 27 studies were included in this meta-analysis. The Cochran Q test and I2 statistics revealed substantial heterogeneity among studies. Based on the random-effects model, the pooled prevalence of ACO was 2.0% (95% CI: 1.4–2.6%) in the general population, 26.5% (95% CI: 19.5–33.6%) among patients with asthma, and 29.6% (95% CI: 19.3–39.9%) among patients with COPD. In addition, for included studies, the global prevalence of asthma-only was 6.2% (95% CI: 5.0–7.4%) and COPD-only was 4.9% (95% CI: 4.3–5.5%). Conclusion: We estimated the global prevalence of ACO based on population-based studies and found that 2.0% of the general population is affected. However, the prevalence of ACO depends on its diagnostic criteria. Therefore, there is a vital need to better define the ACO diagnostic criteria, management and treatment. It is worth noting that the limitations of the present study include lack of studies in some region of the world and small number of studies included in the subgroup analyses. Keywords: Asthma, COPD, Asthma- COPD overlap, Prevalence, Meta-Analysis, Systematic Review Background chronic inflammation of the airways [3, 4]. However, pa- Asthma and chronic obstructive pulmonary disease tients can sometimes have clinical features of both dis- (COPD) are major public health problem and represent a eases, and this condition has been termed asthma-COPD leading cause of morbidity and mortality worldwide [1, 2]. overlap (ACO), recommended by joint GINA (Global Ini- Asthma and COPD are the most common chronic re- tiative for Asthma) and GOLD (Global Initiative for spiratory diseases worldwide each with a unique natural Chronic Obstructive Lung Disease) guideline. According history and pathophysiology [1]. Asthma is usually charac- to this guideline, ACO is characterized by “persistent air- terized by chronic airway inflammation whereas COPD is flow limitation with several features usually associated characterized by persistent respiratory symptoms and with asthma and several features usually associated with COPD”. Furthermore, many studies use the term asthma- COPD overlap syndrome (ACOS), but based on the recent * Correspondence: [email protected] 4School of Nursing and Midwifery, Guilan University of Medical Sciences, change recommended by the GINA and GOLD in 2017, Rasht, Iran we will use ‘ACO’ as a term for this condition as it is not Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Hosseini et al. Respiratory Research (2019) 20:229 Page 2 of 10 considered a single entity but a group of phenotypes [4]. databases were searched with similar terms. Reference Although asthma and COPD have been well defined, there lists from identified studies and relevant review articles is currently no consensus on the definition of ACO. were also searched for studies eligible for inclusion. Most previous studies revealed that patients with ACO have more respiratory symptoms, more frequent exacer- Outcomes bations, poor quality of life, higher mortality rate, in- Our primary outcome of interest was prevalence of creased health care utilization, and higher prevalence of ACO in the general population. Secondary outcomes in- comorbidities than those with either asthma or COPD cluded the prevalence of ACO in patients with asthma only [5–9]. and patients with COPD, prevalence of asthma-only, and Numerous population-based studies have been carried prevalence of COPD-only. Table S1 presents definitions out to estimate the prevalence of ACO throughout the of asthma, COPD, and ACO in included studies. world, especially in the USA and Europe [10–36]. How- ever, there is a considerable variation among the studies. Inclusion and exclusion criteria The prevalence of ACO has varied widely in these stud- The following inclusion criteria were used to select stud- ies from 0.3 to 5.0% in the general population, from 3.2 ies: (1) studies reporting the prevalence of ACO, (2) to 51.4% in patients with asthma, and from 12.6 to population-based studies, (3) studies published in English 55.7% in patients with COPD. Although there are cur- language. No time restriction for publication dates was rently a limited number of population-based studies in used. The following articles were excluded: (1) studies this context, it has been growing in recent years. with no usable data, (2) repeated or overlapping studies, The global prevalence of ACO remains unknown, and and (3) reviews, meta-analysis, and case reports articles. no systematic review and meta-analysis of population- based studies has yet been conducted. On the other Data extraction and quality assessment hand, due to the considerable heterogeneity among the Data were abstracted independently by two authors (SM reported prevalence of ACO, and its significant public and AAH), and discrepancies were resolved by consen- health impact, the exact prevalence of ACO is critical sus. The following study characteristics were extracted: for strategic plan and health policy. We therefore con- first author’s name, year of publication year, country, re- ducted a systematic review and meta-analysis of the pub- gion, study name, study period, age, sample size, and lished literature to examine this parameter. We prevalence of ACO (point or period prevalence). Study examined the prevalence both in the general population quality was assessed independently by two authors (SM and among patients with asthma or COPD to under- and AAH) utilizing the Joanna Briggs Institute’s critical stand better the absolute burden of this condition. appraisal checklist for studies reporting prevalence data [38]. This tool includes 9 items each of which is rated as Methods either yes, no, not clear, or not applicable [38]. This systematic review adheres to the PRISMA (Pre- ferred Reporting Items for Systematic Reviews and Statistical analysis Meta-Analyses) checklist [37]. All meta-analyses were performed using the Stata ver- sion 13.0 (Stata Corp, College Station, TX, USA). The Search strategy Cochran Q test (P < 0.10 was considered indicative of A systematic literature search was performed in ISI Web significant heterogeneity) and the I2 statistic (values of of Knowledge, MEDLINE/PubMed, and Scopus data- 25, 50, and 75% were considered representing low, bases up to 30 May 2019 to identify studies reporting medium and high heterogeneity, respectively) were used the prevalence of ACO. The search strategy in ISI Web to assess the heterogeneity between studies [39]. Due to of Knowledge is outlined in detail in Table 1. The other the substantial heterogeneity between studies, pooled Table 1 Search strategy in database of ISI Web of Knowledge Set Query Results #1 (epidemiology) OR (incidence) OR (Prevalence) OR (Frequency) 3483569 #2 (“Asthma-chronic obstructive pulmonary disease overlap syndrome”) OR (“Asthma and chronic obstructive pulmonary disease overlap 1692 syndrome”) OR (“asthma-COPD overlap syndrome”) OR (“asthma-COPD overlap”) OR (“asthma-COPD”) OR (“ACOS”) OR (“mixed asthma- COPD phenotype”) OR (“Asthma combined with COPD”) OR (“coexistence of asthma and COPD”) OR (“COPD with asthmatic features”) OR (“overlap of asthma-COPD”) #3 (“Pulmonary Disease, Chronic Obstructive”) OR (“Chronic Obstructive Pulmonary Disease”) OR (“COPD”) OR (“asthma”) OR (“asthmatic”) 237,190 OR (“Asthmatic Patient”) #4 #1 AND #2 AND #3 258 Hosseini et al. Respiratory Research (2019) 20:229 Page 3 of 10 prevalence of ACO was calculated using a random- and Canada) [11, 15, 18, 21, 26, 27, 32–34], three East Asia effects model. Potential sources of heterogeneity were (China and Korea) [19, 22, 36], three from the Latin explored through meta-regression and subgroup ana- America and 6 low- and middle-income countries and lyses with regard to the study region, year of publication, Australia [14, 24, 31]. The majority of the included studies and study quality. Egger’s test and a visual inspection of were published after 2015. As presented in Table S2, the funnel plots were used to assess the presence of publica- risk of bias was low in the majority of the criteria in the in- tion bias [40, 41]. cluded studies. Results Study selection Prevalence of ACO in the general population A flow diagram of the study selection process is pre- As seen in Fig.
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