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Severe COPD exacerbation was defined as hospitalization or emergency room visit with one of the following ICD-10 codes as the principal or secondary diagnosis: COPD (J43.X [except J43.0] or J44.X), COPD-related disease (pneumonia [J12.XJ17.X], pulmonary thromboembolism [I26, I26.0, or I26.9], dyspnea [R06.0], or acute respiratory distress syndrome [J80]), and a prescription for systemic steroids or antibiotics at the same visit [26]