Urban-Rural County and State Differences in Chronic Obstructive Pulmonary Disease - United States, 2015

Dietary inflammatory index and all-cause mortality in adults with COPD: a prospective cohort study from the NHANES 1999-2018

Background

Chronic inflammation is closely linked to Chronic Obstructive Pulmonary Disease (COPD); however, the impact of the Dietaryq Inflammatory Index (DII) on mortality among COPD patients remains uncertain.

Objective

To assess the correlation between the DII and all-cause mortality in COPD patients using data from the National Health and Nutrition Examination Survey (NHANES).

Methods

We conducted a retrospective cohort study on 1,820 COPD patients from the NHANES dataset (1999-2018). The influence of DII on mortality was evaluated using multivariate Cox regression, smoothing spline fitting, and threshold effect analysis. Additionally, Kaplan-Meier survival analysis was performed to compare survival curves among different DII groups. Subgroup analyses and E-values identified sensitive cohorts and assessed unmeasured confounding.

Results

Over an average follow-up of 91 months, multivariate Cox regression models revealed a significant positive correlation between DII scores and mortality risk, with each unit increase in DII associated with a 10% higher risk of death (HR: 1.10, 95% CI: 1.03-1.16; P = 0.002). Among the DII tertiles, individuals in the second tertile (T2: 1.23-2.94) experienced a 67% increase in mortality risk compared to those in the lowest tertile (T1: -5.28-1.23) (HR: 1.67, 95% CI: 1.26-2.21; p < 0.001). The third tertile (T3) did not show a statistically significant increase in mortality risk (HR: 1.30, 95% CI: 0.98-1.72; p=0.074). A restricted cubic spline analysis indicated a significant nonlinear association between DII and all-cause mortality (p = 0.021). Threshold effect analysis further revealed that below a DII of 2.19, there was a significant increase in all-cause mortality risk (HR = 1.19, 95% CI: 1.07-1.33; p = 0.002), while at or above this threshold, the risk increase was not statistically significant (HR=0.89, 95% CI: 0.68-1.15; p = 0.380). Kaplan-Meier analysis revealed significant differences in survival curves among DII tertiles (p < 0.001), with the lowest DII tertile showing the highest survival probability. Both subgroup and sensitivity analyses confirmed the robustness of these findings.

Conclusion

DII is positively correlated with mortality risk in COPD patients, showing nonlinear characteristics and threshold effects, underscoring its prognostic value.

Respiratory-related workers' compensation claims from private employers - Ohio, 2001-2018

BACKGROUND

Diseases and conditions related to the respiratory system contribute to work-related morbidity, mortality, and disability. Details on the causes and nature of work-related respiratory disease and the specific industries in which they occur are limited. This study identifies respiratory-related claims in the Ohio Bureau of Workers' Compensation (OHBWC) system and describes claim and worker characteristics to inform public health surveillance.

METHODS

We developed a list of respiratory-related International Classification of Diseases Clinical Modification (ICD-CM) diagnosis codes and searched over 2 million claims filed between 2001 and 2018 in the OHBWC system for at least one of these codes. The claim characteristics, rates of claims by employer industry classification, and causes of claims from narrative text were determined for these respiratory-related claims.

RESULTS

Among the 23,015 respiratory-related claims (5.8 per 10,000 full-time equivalents [FTE]), 54.6% had at least one ICD-CM code for Allergic Reactions and 30.6% had at least one code for Toxic Effects of Substances Chiefly Non-medicinal as to Source. Claim causes from narrative text included Chemical Exposure (30.3%), Activity Suggesting Exposure (24.4%), and Vapors, Gases, Dusts, or Fumes (VGDF) Exposure (19.3%). The highest overall rates of respiratory-related claims among private employers were for the agriculture, forestry & fishing (11.4 per 10,000), public safety (ambulance services) (11.3), and manufacturing (10.7) industry sectors.

CONCLUSIONS

Respiratory-related claims in the OHBWC system were often acute in nature and included allergic reactions. Narratives from these claims provide insight into the work-related exposures and events causing claims or the disease and symptom factors surrounding claims.

Telehealth-guided provider-to-provider communication to improve rural health: A systematic review

INTRODUCTION

Telehealth may address healthcare disparities for rural populations. This systematic review assesses the use, effectiveness, and implementation of telehealth-supported provider-to-provider collaboration to improve rural healthcare.

METHODS

We searched Ovid MEDLINE®, CINAHL®, EMBASE, and Cochrane CENTRAL from 1 January 2010 to 12 October 2021 for trials and observational studies of rural provider-to-provider telehealth. Abstracts and full text were dual-reviewed. We assessed the risk of bias for individual studies and strength of evidence for studies with similar outcomes.

RESULTS

Seven studies of rural uptake of provider-to-provider telehealth documented increases over time but variability across geographic regions. In 97 effectiveness studies, outcomes were similar with rural provider-to-provider telehealth versus without for inpatient consultations, neonatal care, outpatient depression and diabetes, and emergency care. Better or similar results were reported for changes in rural clinician behavior, knowledge, confidence, and self-efficacy. Evidence was insufficient for other clinical uses and outcomes. Sixty-seven (67) evaluation and qualitative studies identified barriers and facilitators to implementing rural provider-to-provider telehealth. Success was linked to well-functioning technology, sufficient resources, and adequate payment. Barriers included lack of understanding of rural context and resources. Methodologic weaknesses of studies included less rigorous study designs and small samples.

DISCUSSION

Rural provider-to-provider telehealth produces similar or better results versus care without telehealth. Barriers to rural provider-to-provider telehealth implementation are common to practice change but include some specific to rural adaptation and adoption. Evidence gaps are partially due to studies that do not address differences in the groups compared or do not include sufficient sample sizes.

Spatial patterns and sociodemographic predictors of chronic obstructive pulmonary disease in Florida

Background

Chronic obstructive pulmonary disease (COPD) is a chronic, inflammatory respiratory disease that obstructs airflow and decreases lung function and is a leading cause death globally. In the United States (US), the prevalence among adults is 6.2%, but increases with age to 12.8% among those 65 years or older. Florida has one of the largest populations of older adults in the US, accounting for 4.5 million adults 65 years or older. This makes Florida an ideal geographic location for investigating COPD as disease prevalence increases with age. Understanding the geographic disparities in COPD and potential associations between its disparities and environmental factors as well as population characteristics is useful in guiding intervention strategies. Thus, the objectives of this study are to investigate county-level geographic disparities of COPD prevalence in Florida and identify county-level socio-demographic predictors of COPD prevalence.

Methods

This ecological study was performed in Florida using data obtained from the US Census Bureau, Florida Health CHARTS, and County Health Rankings and Roadmaps. County-level COPD prevalence for 2019 was age-standardized using the direct method and 2020 US population as the standard population. High-prevalence spatial clusters of COPD were identified using Tango's flexible spatial scan statistics. Predictors of county-level COPD prevalence were investigated using multivariable ordinary least squares model built using backwards elimination approach. Multicollinearity of regression coefficients was assessed using variance inflation factor. Shapiro-Wilks, Breusch Pagan, and robust Lagrange Multiplier tests were used to assess for normality, homoskedasticity, and spatial autocorrelation of model residuals, respectively.

Results

County-level age-adjusted COPD prevalence ranged from 4.7% (Miami-Dade) to 16.9% (Baker and Bradford) with a median prevalence of 9.6%. A total of 6 high-prevalence clusters with prevalence ratios >1.2 were identified. The primary cluster, which was also the largest geographic cluster that included 13 counties, stretched from Nassau County in north-central Florida to Charlotte County in south-central Florida. However, cluster 2 had the highest prevalence ratio (1.68) and included 10 counties in north-central Florida. Together, the primary cluster and cluster 2 covered most of the counties in north-central Florida. Significant predictors of county-level COPD prevalence were county-level percentage of residents with asthma and the percentage of current smokers.

Conclusions

There is evidence of spatial clusters of COPD prevalence in Florida. These patterns are explained, in part, by differences in distribution of some health behaviors (smoking) and co-morbidities (asthma). This information is important for guiding intervention efforts to address the condition, reduce health disparities, and improve population health.

Survival disparities in rural versus urban patients with pancreatic neuroendocrine tumor: A multi-institutional study from the US neuroendocrine tumor study group

BACKGROUND

Pancreatic Neuroendocrine Tumors (PNETs) are indolent malignancies that often have a prolonged clinical course. This study assesses disparities in outcomes between PNET patients who live in urban (UA) and rural areas (RA).

METHODS

A retrospective cohort study was performed using the US Neuroendocrine Tumor Study Group database. PNET patients with a home zip code recorded were included and categorized as RA or UA according to the Federal Office of Rural Health Policy. Overall survival (OS) was analyzed by Kaplan-Meier method, log-rank test, and logistical regression.

RESULTS

Of the 1176 PNET patients in the database, 1126 (96%) had zip code recorded. While 837 (74%) lived in UA, 289 (26%) lived in RA. RA patients had significantly shorter median OS following primary PNET resection (122 vs 149 months, p ​= ​0.01). After controlling for income, local healthcare access, distance from treatment center, ASA class, BMI, and T/N/M stage, living in a RA remained significantly associated with worse OS (HR 1.60, 95%CI 1.08-2.39, p ​= ​0.02).

CONCLUSION

Rural patients have significantly shorter OS following PNET resection compared to their urban counterparts.

Health and Demographic Factors for Chronic Obstructive Pulmonary Disease Among Hispanic Adults in the United States: Analysis of Behavioral Risk Factor Surveillance System Survey Data

Introduction: Appropriate diagnosis and regular primary care appointments are markers of quality chronic obstructive pulmonary disease (COPD) care. Underdiagnosis of COPD has been associated with an absence of health insurance, lower socioeconomic status, and race and ethnicity. Methods: This study examined predictors of COPD using data from the Behavioral Risk Factor Surveillance System (BRFSS, 2021) to provide information for prevention messaging and interventions. Participants included Hispanic adults (n = 17,782) aged 45 years and older. Chi-square tests and a multinomial logistic regression analysis (adjusted with the BRFSS weighting variable) were used to understand how sex, income, health status, smoking behaviors, asthma morbidity, and health insurance coverage were related to having COPD. Results: Patients with poor health, lower income level, current smokers, former smokers, or asthma were more likely to report COPD. Females were more likely to report COPD than males. Patients with COPD were more likely to be without health insurance when compared to those who did not have COPD, indicating unmet medical needs. Conclusion: Studies such as this one, aiming to evaluate the relationship between COPD prevalence and predictors of health and outcomes among Hispanic patients in the United States will remain important for developing health messaging to attenuate disease progression.

Urban-rural and socio-economic differences in inhaled corticosteroid treatment for chronic obstructive pulmonary disease: A nationwide register-based cross-sectional study

BACKGROUND

Urban-rural disparities within chronic obstructive pulmonary disease (COPD) have been documented in USA, but not in Europe. Inhaled corticosteroids (ICS) are widely used in COPD despite strict recommendations. We aimed to investigate urban-rural and socioeconomic differences in ICS treatment for COPD.

METHODS

A Danish nationwide register-based cross-sectional study. All patients alive on the December 31, 2018 with a J44 ICD-10 diagnosis code (COPD) were included (99,057 patients). Daily average ICS dose was calculated from the accumulated ICS use during 2018 based on redeemed prescriptions. Patients were divided into groups: No ICS, low dose ICS, medium dose ICS, high dose ICS. A multinomial logistic regression model including educational level, co-habitation status, age, and sex was performed with "No ICS" as reference group.

RESULTS

Compared to capital municipalities, living in other municipality types was associated with an increased probability of receiving medium and high dose ICS treatment, and increasing odds ratios (ORs) were seen with increasing ICS dose (medium dose ICS: ORs between 1.31 (95 % confidence interval (CI) 1.24-1.38) and 1.35 (95%CI 1.28-1.41), high dose ICS: ORs between 1.73 (95%CI 1.59-1.88) and 1.80 (95%CI 1.68-1.92)). Patients had increased probability of receiving ICS treatment if they were female, were co-habiting, or had completed only primary education.

CONCLUSION

Patients with a hospital-registered COPD diagnosis in non-capital municipalities receive more ICS, and in higher doses, compared to patients in capital municipalities. This is the first study to confirm that such urban-rural differences exist in Europe, and further research on this area is warranted.

National and Local Direct Medical Cost Burden of COPD in the United States From 2016 to 2019 and Projections Through 2029

BACKGROUND

Despite the significant burden posed by COPD to health care systems, there is a lack of up-to-date information quantifying the general COPD burden, costs, and long-term projections to various stakeholders in the United States.

RESEARCH QUESTION

What are the updated state-specific and nationwide estimates of the COPD disease burden and direct costs in 2019, along with projections of COPD-attributable medical costs through 2029?

STUDY DESIGN AND METHODS

A cross-sectional, retrospective study design using the 2016 to 2019 Medical Expenditure Panel Survey, 2019 American Community Survey, and 2019 Behavioral Risk Factor Surveillance System data was applied to generate COPD-attributable expenditure estimates. Cost projections for the years 2020 to 2029 were based on 2017 national population projections reported by the US Census Bureau, and all costs were adjusted to 2019 US dollars.

RESULTS

In total, 4,135 people living with COPD were included; a higher proportion had other concurrent conditions such as cardiovascular-related conditions compared with people without COPD (n = 86,021). Overall, in 2019, COPD-attributable medical costs after adjusting for demographic characteristics and 19 concurrent conditions (including COPD-related and non-COPD-related conditions) were estimated at $31.3 billion, with state-specific cost estimates reporting wide variation, from $44.8 million in Alaska to $3.1 billion in Florida. Nationwide COPD-attributable medical costs borne by payer type were as follows: private insurance, $11.4 billion; Medicare, $10.8 billion; and Medicaid, $3.0 billion. Projections of national medical costs attributable to COPD are reported to increase to $60.5 billion in 2029.

INTERPRETATION

Understanding the current disease and economic burden of COPD in the United States, along with the projected costs attributable to COPD in the next decade, will highlight unmet needs and gaps in care that help inform health care decision-makers in planning future actions to alleviate this disease burden.

Association of Frailty with Patient-Report Outcomes and Major Clinical Determinants in Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease

Purpose

This study aimed to explore the correlation of frailty status with disease characteristics and patient-reported outcomes (PROs) in patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) and determine the sensitivity and specificity of modified COPD PRO scale (mCOPD-PRO) for detecting frailty.

Patients and Methods

This cross-sectional study surveyed 315 inpatients with AECOPD from a tertiary hospital in China from August 2022 to June 2023. Patient frailty and PROs were assessed using the validated FRAIL scale and mCOPD-PRO, respectively. Spearman's ρ was used to assess the relevance of lung disease indicators commonly used in clinical practice, and ordinal logistic regression analyses were used to identify the variables associated with frailty status. The validity of mCOPD-PRO in discriminating frail or non-frail individuals was determined using the receiver operating characteristic curve.

Results

The participants (N=302, mean age 72.4±9.1 years) were predominantly males (73.2%). Among them, 43 (14.3%) patients were not frail, whereas 123 (40.7%) and 136 (45.0%) patients were pre-frail and frail, respectively. The FRAIL scale was moderately correlated with the mCOPD-PRO scores (Spearman's rank correlation coefficient [Rs]=0.52, P<0.01) for all dimensions (Rs=0.43-0.49, P<0.01). Patients residing in rural areas (odds ratio [OR], 1.67; 95% confidence interval [95% CI], 1.01-2.76) and with higher mCOPD-PRO scores (OR, 4.78; 95% CI, 2.75-8.32) were more likely to be frail. Physically active patients (OR, 0.42; 95% CI, 0.21-0.84) were less likely to be frail. In addition, mCOPD-PRO had good discriminate validity for detecting frailty (area under the curve=0.78), with a sensitivity and specificity of 84.6% and 60.8%, respectively. The optimal probability threshold for mCOPD-PRO was ≥1.52 points.

Conclusion

In patients with AECOPD, frailty is closely related to PROs and disease characteristics. Additionally, the mCOPD-PRO score can distinguish well between frail and non-frail patients. Our findings provide support for interventions targeting frail populations with AECOPD.

Closing the Last Mile Gap in Access to Multimodality Imaging in Rural Settings: Design of the Imaging Core of the Risk Underlying Rural Areas Longitudinal Study

Achieving optimal cardiovascular health in rural populations can be challenging for several reasons including decreased access to care with limited availability of imaging modalities, specialist physicians, and other important health care team members. Therefore, innovative solutions are needed to optimize health care and address cardiovascular health disparities in rural areas. Mobile examination units can bring imaging technology to underserved or remote communities with limited access to health care services. Mobile examination units can be equipped with a wide array of assessment tools and multiple imaging modalities such as computed tomography scanning and echocardiography. The detailed structural assessment of cardiovascular and lung pathology, as well as the detection of extracardiac pathology afforded by computed tomography imaging combined with the functional and hemodynamic assessments acquired by echocardiography, yield deep phenotyping of heart and lung disease for populations historically underrepresented in epidemiological studies. Moreover, by bringing the mobile examination unit to local communities, innovative approaches are now possible including engagement with local professionals to perform these imaging assessments, thereby augmenting local expertise and experience. However, several challenges exist before mobile examination unit-based examinations can be effectively integrated into the rural health care setting including standardizing acquisition protocols, maintaining consistent image quality, and addressing ethical and privacy considerations. Herein, we discuss the potential importance of cardiac multimodality imaging to improve cardiovascular health in rural regions, outline the emerging experience in this field, highlight important current challenges, and offer solutions based on our experience in the RURAL (Risk Underlying Rural Areas Longitudinal) cohort study.

Rural disparities impact response to a web-based physical activity self-management intervention in COPD: A secondary analysis

PURPOSE

This secondary exploratory analysis examined rural-urban differences in response to a web-based physical activity self-management intervention for chronic obstructive pulmonary disease (COPD).

METHODS

Participants with COPD (N = 239 US Veterans) were randomized to either a multicomponent web-based intervention (goal setting, iterative feedback of daily step counts, motivational and educational information, and an online community forum) or waitlist-control for 4 months with a 12-month follow-up. General linear modeling estimated the impact of rural/urban status (using Rural-Urban Commuting Area [RUCA] codes) on (1) 4- and 12-month daily step-count change compared to waitlist-control, and (2) intervention engagement (weekly logons and participant feedback).

FINDINGS

Rural (n = 108) and urban (n = 131) participants' mean age was 66.7±8.8 years. Rural/urban status significantly moderated 4-month change in daily step counts between randomization groups (p = 0.041). Specifically, among urban participants, intervention participants improved by 1500 daily steps more than waitlist-control participants (p = 0.001). There was no difference among rural participants. In the intervention group, rural participants engaged less with the step-count graphs on the website than urban participants at 4 months (p = 0.019); this difference dissipated at 12 months. More frequent logons were associated with greater change in daily step counts (p = 0.004); this association was not moderated by rural/urban status.

CONCLUSIONS

The web-based intervention was effective for urban, but not rural, participants at 4 months. Rural participants were also less engaged at 4 months, which may explain differences in effectiveness. Technology-based interventions can help address urban-rural disparities in patients with COPD, but may also contribute to them unless resources are available to support engagement with the technology.

Risk of Atherosclerotic Cardiovascular Disease Hospitalizations after COPD Hospitalization among Older Adults

BACKGROUND

Meta-analyses have suggested the risk of atherosclerotic cardiovascular disease (ASCVD) events is significantly higher after a chronic obstructive pulmonary disease (COPD) exacerbation. However, these studies have been limited to highly selected patient populations potentially not generalizable to the broader population of COPD.

METHODS

We assessed the risk of ASCVD hospitalizations after COPD hospitalization compared to before COPD hospitalization and identified patient factors associated with ASCVD hospitalizations after COPD hospitalization. This retrospective cohort study used claims data from 920,550 Medicare beneficiaries hospitalized for COPD from 2016-2019 in the US. The primary outcome was risk of a ASCVD hospitalization composite outcome (myocardial infarction, percutaneous coronary intervention, coronary artery by-pass graft surgery, stroke, or transient ischemic attack) in the 1 year after-COPD hospitalization relative to the 1 year before-COPD hospitalization. Time from discharge to a composite ASCVD hospitalization outcome was modeled using an extension of the Cox Proportional-Hazards model, the Anderson-Gill model with adjustment for patient characteristics. Additional analyses evaluated for interactions in subgroups and risk factors associated with the composite ASCVD hospitalization outcome.

RESULTS

Among 920,550 patients (mean age, 73 years) the hazard ratio estimate (HR; 95% CI) for the composite ASCVD hospitalization outcome after-COPD hospitalization vs before-COPD hospitalization was 0.99 (0.97, 1.02; p = 0.53) following adjustment. We observed 3 subgroups that were significantly associated with higher risk for ASCVD hospitalizations after COPD hospitalization: 76+ years old, women, COPD hospitalization severity. Among the 19 characteristics evaluated, 10 were significantly associated with higher risk of CVD events 1 year after COPD hospitalization with hyperlipidemia (2.78; 2.67, 2.90) and history of cardiovascular disease (1.77; 1.72 1.83) associated with the greatest risk.

CONCLUSION

Among Medicare beneficiaries hospitalized for COPD, the risk of ASCVD hospitalizations was not significantly increased after COPD-hospitalization relative to before-COPD hospitalization. Although, we identified age 76+ years old, female sex, and COPD hospitalization severity as high risk subgroups and 10 risk factors associated with increased risk of ASCVD events after-COPD hospitalization. Further research is needed to characterize the COPD exacerbation populations at highest ASCVD hospitalization risk.

Adverse health outcomes among rural prostate cancer survivors: A population-based study

INTRODUCTION

Rural cancer survivors experience considerable health disparities compared to urban cancer survivors for cancer treatment and survival. The objective of our study was to investigate the risk of developing diseases for rural compared to urban prostate cancer survivors in Utah.

METHODS

We identified a cohort of 3575 rural prostate cancer survivors and 17,778 urban prostate cancer survivors from the Utah Cancer Registry. The Fine-Gray subdistribution hazards model was used to estimate hazard ratios and 95 % confidence intervals for diseases in major body systems among rural compared to urban prostate cancer survivors at > 1-5 years and > 5 years after prostate cancer diagnosis.

RESULTS

Rural residence was associated with an increased risk of diseases of the respiratory system at > 5 years (HR: 1.16, 95 % CI: 1.01-1.32) after cancer diagnosis compared to urban residence among prostate cancer survivors in Utah. Decreased risks were observed in infectious and parasitic diseases, diseases of the blood and blood-forming organs, diseases of the nervous system and sense organs, and diseases of the skin and subcutaneous tissue for rural prostate cancer survivors between 1 and 5 years after cancer diagnosis.

CONCLUSIONS

Rural prostate cancer survivors in Utah were somewhat healthier compared to urban prostate cancer survivors. Further studies are needed to confirm whether these associations are also supported for rural prostate cancer survivors in other regions of the U.S.

Inequality of opportunity in outpatient expenditure among the elderly with multimorbidity: evidence from China

BACKGROUND

Inequality of opportunity (IOp) stemming from social circumstances exists in outpatient service utilization for the multimorbid elderly in China. However, little is known regarding the magnitude of the IOp and its composition. Therefore, this study aims to measure the IOp in outpatient expenditure and provide potential pathways for policy reform by assessing the contribution of each circumstance.

METHODS

This study included 3527 elderly aged ≥ 65 years with multimorbidity from the Chinese Longitudinal Healthy Longevity Study conducted in 2017-2018. An ordinary least squares regression model was used to analyze the circumstance-influencing factors of outpatient expenditure. The parametric approach was performed to quantify the IOp in outpatient expenditure and the Shapley value decomposition method was employed to determine the contribution of each circumstance. By extracting heterogeneity in the residual of the circumstance-dependent equation of outpatient expenditure across circumstance groups divided based on cluster analysis, we captured the effect of unobserved circumstances.

RESULTS

Except for pension and distance to health facilities, all the associations between circumstance and outpatient expenditure were statistically significant. The inequality caused by circumstances accounted for 25.18% of the total inequality. The decomposition results revealed that the reimbursement rate contributed 82.92% of the IOp, followed by education duration (4.55%), household registration (3.21%), household income (3.18%), pension (1.49%), medical insurance (1.26%), physical labor (0.99%), unobserved circumstances (0.86%), distance to health facilities (0.83%) and region (0.71%).

CONCLUSIONS

The priority of policy enhancement is to effectively improve the outpatient reimbursement benefit for treating chronic diseases. Additional crucial actions include enhancing the health literacy of the multimorbid elderly to promote the shift from medical needs to demands and accelerating the construction of rural capacity for providing high-quality healthcare to the elderly with multimorbidity.

The association of forced expiratory volume in one second with occupational exposures in a longitudinal study of adults in a rural community in Iowa

PURPOSE

The Keokuk County Rural Health Study (KCRHS) is a longitudinal population-based study conducted in rural Iowa. A prior analysis of enrollment data identified an association of airflow obstruction with occupational exposures only among cigarette smokers. The current study used spirometry data from all three rounds to investigate whether level of forced expiratory volume in one second (FEV1) and longitudinal change in FEV1 were associated with occupational vapor-gas, dust, and fumes (VGDF) exposures, and whether these associations were modified by smoking.

METHODS

This study sample comprised 1071 adult KCRHS participants with longitudinal data. A job-exposure matrix (JEM) was applied to participants' lifetime work histories to assign exposures to occupational VGDF. Mixed regression models of pre-bronchodilator FEV1 (millimeters, ml) were fit to test for associations with occupational exposures while adjusting for potential confounders.

RESULTS

Mineral dust had the most consistent association with change in FEV1, including ever/never ( - 6.3 ml/year) and nearly every level of duration, intensity, and cumulative exposure. Because 92% of participants with mineral dust also had organic dust exposure, the results for mineral dust may be due to a combination of the two. An association of FEV1 level with fumes was observed for high intensity ( - 91.4 ml) among all participants, and limited to cigarette smokers with results of  - 104.6 ml ever/never exposed,  - 170.3 ml high duration, and  - 172.4 ml high cumulative.

CONCLUSION

The current findings suggest that mineral dust, possibly in combination with organic dust, and fumes exposure, especially among cigarette smokers, were risk factors for adverse FEV1 results.

Sociodemographic and Geographic Risk Factors for All-Cause Mortality in Patients with COPD

Background

Chronic obstructive pulmonary disease (COPD) is a leading cause of mortality worldwide. Identifying both individual and community risk factors associated with higher mortality is essential to improve outcomes. Few population-based studies of mortality in COPD include both individual characteristics and community risk factors.

Objective

We used geocoded, patient-level data to describe the associations between individual demographics, neighborhood socioeconomic status, and all-cause mortality.

Methods

We performed a nationally representative retrospective cohort analysis of all patients enrolled in the Veteran Health Administration with at least one ICD-9 or ICD-10 code for COPD in 2016-2019. We obtained demographic characteristics, comorbidities, and geocoded residential address. Area Deprivation Index and rurality were classified using individual geocoded residential addresses. We used logistic regression models to assess the association between these characteristics and age-adjusted all-cause mortality.

Results

Of 1,106,163 COPD patients, 33.4% were deceased as of January 2021. In age-adjusted models, having more comorbidities, Black/African American race (OR 1.09 [95% CI: 1.08-1.11]), and higher neighborhood disadvantage (OR 1.30 [95% CI: 1.28-1.32]) were associated with all-cause mortality. Female sex (OR 0.67 [95% CI: 0.65-0.69]), Asian race (OR 0.64, [95% CI: 0.59-0.70]), and living in a more rural area were associated with lower odds of all-cause mortality. After adjusting for age, comorbidities, neighborhood socioeconomic status, and rurality, the association with Black/African American race reversed.

Conclusion

All-cause mortality in COPD patients is disproportionately higher in patients living in poorer neighborhoods and urban areas, suggesting the impact of social determinants of health on COPD outcomes. Black race was associated with higher age-adjusted all-cause mortality, but this association was abrogated after adjusting for gender, socioeconomic status, comorbidities, and urbanicity. Future studies should focus on exploring mechanisms by which disparities arise and developing interventions to address these.

Acute exacerbation of chronic obstructive pulmonary disease in United States emergency departments, 2010-2018

OBJECTIVES

Little is known about the recent status of acute exacerbation of chronic obstructive pulmonary disease (AECOPD) in the U.S. emergency department (ED). This study aimed to describe the disease burden (visit and hospitalization rate) of AECOPD in the ED and to investigate factors associated with the disease burden of AECOPD.

METHODS

Data were obtained from the National Hospital Ambulatory Medical Care Survey (NHAMCS), 2010-2018. Adult ED visits (aged 40 years or above) with AECOPD were identified using International Classification of Diseases codes. Analysis used descriptive statistics and multivariable logistic regression accounting for NHAMCS's complex survey design.

RESULTS

There were 1,366 adult AECOPD ED visits in the unweighted sample. Over the 9-year study period, there were an estimated 7,508,000 ED visits for AECOPD, and the proportion of AECOPD visits in the entire ED population remained stable at approximately 14 per 1,000 visits. The mean age of these AECOPD visits was 66 years, and 42% were men. Medicare or Medicaid insurance, presentation in non-summer seasons, the Midwest and South regions (vs. Northeast), and arrival by ambulance were independently associated with a higher visit rate of AECOPD, whereas non-Hispanic black or Hispanic race/ethnicity (vs. non-Hispanic white) was associated with a lower visit rate of AECOPD. The proportion of AECOPD visits that were hospitalized decreased from 51% to 2010 to 31% in 2018 (p = 0.002). Arrival by ambulance was independently associated with a higher hospitalization rate, whereas the South and West regions (vs. Northeast) were independently associated with a lower hospitalization rate. The use of antibiotics appeared to be stable over time, but the use of systemic corticosteroids appeared to increase with near statistical significance (p = 0.07).

CONCLUSIONS

The number of ED visits for AECOPD remained high; however, hospitalizations for AECOPD appeared to decrease over time. Some patients were disproportionately affected by AECOPD, and certain patient and ED factors were associated with hospitalizations. The reasons for decreased ED admissions for AECOPD deserve further investigation.

Assessment of health status and its correlation with lung function in patients with chronic obstructive pulmonary disease: a study from a tertiary care center in north India

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2023 recommends a comprehensive multidimensional assessment for patients with chronic obstructive pulmonary disease (COPD) and stresses the need for evaluation of their health status and quality of life (QOL). The COPD assessment test (CAT), clinical COPD questionnaire (CCQ), and St. George respiratory questionnaire (SGRQ) are recommended by GOLD for such assessments. However, their correlation with spirometry in the Indian population is not known. Other similar questionnaires like the COPD and sleep impact scale (CASIS), functional performance inventory-short form (FPI-SF), and COPD and asthma fatigue scale (CAFS), though used internationally as a research tool, are still in the offspring stage and have never been used in India. A cross-sectional study was hence conducted in the Department of Pulmonary Medicine, Government Medical College, Patiala, Punjab, India, on 100 COPD patients. Patients were assessed for health status and QOL by CAT, CCQ, SGRQ, CASIS, FPI-SF, and CAFS. The relationship between these questionnaires and airflow limitations was investigated. The majority of the patients were males (n=97), >50 years of age (n=83), illiterate (n=72), had moderate/severe COPD, and belonged to group B (n=66). The mean value of forced expiratory volume in one second (FeV1) decreased with a deterioration in CAT and CCQ score grouping (p<0.001). Patients with poorer CAT and CCQ scores belonged to higher GOLD grades (k=0.33, p<0.001). The correlation of health-related quality of life (HRQL) questionnaires among each other, with FEV1 predicted and with GOLD grade, was strong to very strong in most of the comparisons (p<0.01 in the majority). On comparison of GOLD grade with mean scores of HRQL questionnaires, it was seen that with the increase in GOLD grading from 1 to 4, the mean values of CAT, CCQ, SGRQ, CASIS, FPI-SF, and CAFS also deteriorated (p<0.001, p<0.001, p<0.001, p<0.005, p<0.001 and p<0.001, respectively). Various easy-to-use HRQL scores should be routinely used in outpatient departments for a comprehensive assessment of COPD patients. These questionnaires, in combination with clinical features, can help in providing a rough estimate of the severity of the disease in places where lung function assessments are not readily available.

Budget impact analysis of a digital monitoring platform for COPD

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a progressive debilitating condition with frequent exacerbations that have a high burden for patients and society. Digital tools may help to reduce the economic burden for patients and payers by improving outcomes. The Propeller platform is a digital self-management tool that facilitates passive monitoring of inhaler medication utilization, potentially assisting the healthcare team to identify patients at risk of a COPD exacerbation who may require further intervention. This study estimated the budget impact of Propeller from commercial payer and Medicare fee-for-service payer perspectives.

METHODS

An Excel-based model was used to estimate the budget impact of Propeller for COPD patients in commercial and Medicare population sizes of 5 million members. Data on prevalence, baseline healthcare resource utilization (HCRU), and baseline use of rescue and controller inhaler medications with unit costs (adjusted to 2020 US dollars) were obtained from peer-reviewed literature. Data on reductions in HCRU during Propeller usage were based on direct evidence. Estimates for costs of remote monitoring were obtained from publicly available information. All patients were assumed to have insurance claims related to ongoing remote monitoring.

RESULTS

The estimated number of annual eligible COPD patients for commercial and Medicare was 212,200 and 606,600, respectively. Propeller decreased costs by an estimated $2,475 (commercial) and $915 (Medicare) per enrolled patient. The greatest increase in expenditure was for remote monitoring related expenses. After accounting for estimated reductions in hospitalizations, emergency department visits and short-acting beta-agonist use, total net savings were approximately $1.60 and $1.70 per-member per-month for commercial and Medicare payers, respectively.

CONCLUSION

Propeller is projected to be cost saving from both the commercial and Medicare payer perspectives.

Association of rural living with COPD-related hospitalizations and deaths in US veterans

It is unclear whether the high burden of COPD in rural areas is related to worse outcomes in patients with COPD or is because the prevalence of COPD is higher in rural areas. We assessed the association of rural living with acute exacerbations of COPD (AECOPDs)-related hospitalization and mortality. We retrospectively analyzed Veterans Affairs (VA) and Medicare data of a nationwide cohort of veterans with COPD aged ≥ 65 years with COPD diagnosis between 2011 and 2014 that had follow-up data until 2017. Patients were categorized based on residential location into urban, rural, and isolated rural. We used generalized linear and Cox proportional hazards models to assess the association of residential location with AECOPD-related hospitalizations and long-term mortality. Of 152,065 patients, 80,162 (52.7%) experienced at least one AECOPD-related hospitalization. After adjusting for demographics and comorbidities, rural living was associated with fewer hospitalizations (relative risk-RR = 0.90; 95% CI: 0.89-0.91; P < 0.001) but isolated rural living was not associated with hospitalizations. Only after accounting for travel time to the closest VA medical center, neighborhood disadvantage, and air quality, isolated rural living was associated with more AECOPD-related hospitalizations (RR = 1.07; 95% CI: 1.05-1.09; P < 0.001). Mortality did not vary between rural and urban living patients. Our findings suggest that other aspects than hospital care may be responsible for the excess of hospitalizations in isolated rural patients like poor access to appropriate outpatient care.

Trends and Rural-Urban Differences in the Initial Prescription of Low-Value Inhaled Corticosteroids among U.S. Veterans with Chronic Obstructive Pulmonary Disease

Rationale: Guidelines recommend inhaled corticosteroids (ICS) for patients with chronic obstructive pulmonary disease (COPD) and select indications, including asthma history, high exacerbation risk, or high serum eosinophils. ICS are commonly prescribed outside of these indications, despite evidence of harm. We defined a "low-value" ICS prescription as the receipt of an ICS without evidence of a guideline-recommended indication. ICS prescription patterns are not well characterized and could inform health system interventions to reduce low-value practices. Objectives: To evaluate the national trends in initial low-value ICS prescriptions in the U.S. Department of Veterans Affairs and to determine whether rural-urban differences in low-value ICS prescribing exist. Methods: We performed a cross-sectional study between January 4, 2010, and December 31, 2018, identifying veterans with COPD who were new users of inhaler therapy. We defined low-value ICS as prescriptions in patients with 1) no asthma, 2) low risk of future exacerbation (Global Initiative for Chronic Obstructive Lung Disease group A or B), and 3) serum eosinophils <300 cells/μl. We performed multivariable logistic regression to evaluate trends in low-value ICS prescription over time, adjusting for potential confounders. We performed fixed effects logistic regression to assess rural-urban prescribing patterns. Results: We identified a total of 131,009 veterans with COPD starting inhaler therapy, 57,472 (44%) of whom were prescribed low-value ICS as initial therapy. From 2010 to 2018, the probability of receiving low-value ICS as initial therapy increased by 0.42 percentage points per year (95% confidence interval, 0.31-0.53). Compared with urban residence, rural residence was associated with a 2.5-percentage-point (95% confidence interval, 1.9-3.1) higher probability of receiving low-value ICS as initial therapy. Conclusions: The prescription of low-value ICS as initial therapy is common and increasing slightly over time for both rural and urban veterans. Given the widespread and persistent nature of low-value ICS prescribing, health system leaders should consider system-wide approaches to address this low-value prescribing practice.

Strategies to Improve Enrollment and Participation in Pulmonary Rehabilitation Following a Hospitalization for COPD: RESULTS OF A NATIONAL SURVEY

PURPOSE

Pulmonary rehabilitation (PR) improves outcomes for patients with chronic obstructive pulmonary disease (COPD); however, very few patients attend. We sought to describe strategies used to promote participation in PR after a hospitalization for COPD.

METHODS

A random sample of 323 United States based PR programs was surveyed. Using a positive deviance approach, a 39-item survey was developed based on interviews with clinicians at hospitals demonstrating high rates of participation in PR. Items focused on strategies used to promote participation as well as relevant contextual factors.

RESULTS

Responses were received from 209 programs (65%), of which 88% (n = 184) were hospital-based outpatient facilities. Most (91%, n = 190) programs described enrolling patients continuously, and 80% (n = 167) reported a wait time from referral to the initial PR visit of <4 wk. Organization-level strategies to increase referral to PR included active surveillance (48%, n = 100) and COPD-focused staff (49%, n = 102). Provider-level strategies included clinician education (45%, n = 94), provider outreach (43%, n = 89), order sets (45%, n = 93), and automated referrals (23%, n = 48). Patient-level strategies included bedside education (53%, n = 111), flyers (49%, n = 103), motivational interviewing (33%, n = 69), financial counseling (64%, n = 134), and transportation assistance (35%, n = 73). Fewer than one-quarter (18%, n = 38) of PR programs reported using both bedside education and automatic referral, and 42% (n = 88) programs did not use either strategy.

CONCLUSIONS

This study describes current practices in the United States, and highlights opportunities for improvement at the organization, provider, and patient level. Future research needs to demonstrate the effectiveness of these strategies, alone or in combination.

Most patients with COPD are unaware of their health threats and are not diagnosed: a national-level study using pulmonary function test

This study aimed to investigate national-level prevalence of COPD, proportion of patients diagnosed with and without COPD. We performed pulmonary function test (PFT) in 24,454 adults aged > 40 years for 8 years (2010-2017). The annual COPD prevalence increased from 13.1% in 2010 to 14.6% in 2012, followed by 13.3% in 2017. However, patients diagnosed with COPD ranged between 0.5 and 1.0% in the last 8 years, which means that only 5% of all COPD patients were diagnosed with COPD by doctors. We defined potential high-risk individuals as those with a FEV₁/FVC ratio of < 0.70, who have not been diagnosed with COPD and other respiratory diseases tuberculosis, asthma, lung cancer. The proportion of this group was 80.8% in 2010 and 78.1% in 2017. The older age group, women, low-educated group, and current smokers who have been smoking for a long time are more likely to be in the high-risk group having a higher possibility to develop COPD but are not diagnosed with COPD appropriately. Although COPD prevalence was high in the ever, current, and heavy smokers, only the diagnosis rate of COPD in ever smokers was 2.38 times higher than never smokers, indicating that a system is needed to screen and intervention for these groups.

Evaluation Design for The Two Georgias Initiative: Assessing Progress Toward Health Equity in the Rural South

As persistent inequities in health gained increased attention nationally due to COVID-19 and racial justice protests in 2020, it has become increasingly important to evaluate both the process and outcomes associated with coalition-based efforts to address health inequities. The Two Georgias Initiative supports coalitions in 11 rural counties to (1) achieve greater health equity, (2) improve health and health care, (3) build healthier rural communities and improve social conditions that impact the health of rural populations, and (4) build community, organizational, and individual leadership capacity for health equity. Rural communities suffer significant health disparities relative to urban areas, and also experience internal inequities by race and poverty level. The evaluation framework for The Two Georgias Initiative provides a comprehensive mixed methods approach to evaluating both processes and outcomes. Early results related to community readiness and capacity to address health inequities, measured through a coalition member survey (n = 236) conducted at the end of the planning phase, suggest coalitions were in the preparation stage, with higher levels of readiness among coalition members and organizations/groups similar to the coalition members' own, lower levels among public officials and other leaders, and the lowest levels among county residents. In addition, coalition members reported more experience with downstream drivers (e.g., access to care) of health than upstream drivers (e.g., affordable housing, environmental or racial justice). By providing a logic model, evaluation questions and associated indicators, as well as a range of data collection methods, this evaluation approach may prove practical to others aiming to evaluate their efforts to address health equity.

Among-Hospital Variation in Intensive Care Unit Admission Practices and Associated Outcomes for Patients with Acute Respiratory Failure

Rationale: We have previously shown that hospital strain is associated with intensive care unit (ICU) admission and that ICU admission, compared with ward admission, may benefit certain patients with acute respiratory failure (ARF). Objectives: To understand how strain-process-outcomes relationships in patients with ARF may vary among hospitals and what hospital practice differences may account for such variation. Methods: We examined high-acuity patients with ARF who did not require mechanical ventilation or vasopressors in the emergency department (ED) and were admitted to 27 U.S. hospitals from 2013 to 2018. Stratifying by hospital, we compared hospital strain-ICU admission relationships and hospital length of stay (LOS) and mortality among patients initially admitted to the ICU versus the ward using hospital strain as a previously validated instrumental variable. We also surveyed hospital practices and, in exploratory analyses, evaluated their associations with the above processes and outcomes. Results: There was significant among-hospital variation in ICU admission rates, in hospital strain-ICU admission relationships, and in the association of ICU admission with hospital LOS and hospital mortality. Overall, ED patients with ARF (n = 45,339) experienced a 0.82-day shorter median hospital LOS if admitted initially to the ICU compared with the ward, but among the 27 hospitals (n = 224-3,324), this effect varied from 5.85 days shorter (95% confidence interval [CI], -8.84 to -2.86; P < 0.001) to 4.38 days longer (95% CI, 1.86-6.90; P = 0.001). Corresponding ranges for in-hospital mortality with ICU compared with ward admission revealed odds ratios from 0.08 (95% CI, 0.01-0.56; P < 0.007) to 8.89 (95% CI, 1.60-79.85; P = 0.016) among patients with ARF (pooled odds ratio, 0.75). In exploratory analyses, only a small number of measured hospital practices-the presence of a sepsis ED disposition guideline and maximum ED patient capacity-were potentially associated with hospital strain-ICU admission relationships. Conclusions: Hospitals vary considerably in ICU admission rates, the sensitivity of those rates to hospital capacity strain, and the benefits of ICU admission for patients with ARF not requiring life support therapies in the ED. Future work is needed to more fully identify hospital-level factors contributing to these relationships.

Exacerbation in patients with stable COPD in China: analysis of a prospective, 52-week, nationwide, observational cohort study (REAL)

BACKGROUND

Chronic obstructive pulmonary disease (COPD) management in China is inadequate and there is a need to improve care and outcomes for patients nationwide.

OBJECTIVES

The REAL study was designed to generate reliable information on COPD management from a representative sample of Chinese patients with COPD. Here, we present study outcomes related to acute exacerbations.

DESIGN

A 52-week, multicentre, prospective, observational study.

METHODS

Outpatients (aged ⩾ 40 years) enrolled from 25 tertiary and 25 secondary hospitals across six geographic regions in China were followed for 12 months. Risk factors for COPD exacerbation and disease severity by exacerbation were assessed using multivariate Poisson and ordinal logistic regression models, respectively.

RESULTS

Between June 2017 and January 2019, 5013 patients were enrolled, with 4978 included in the analysis. Mean (standard deviation) age was 66.2 (8.9) years. More patients presented with exacerbations in secondary versus tertiary hospitals (59.4% versus 40.2%) and in rural versus urban areas (53.2% versus 46.3%). Overall exacerbation rates differed across regions (range: 0.27-0.84). Patients from secondary versus tertiary hospitals had higher rates of overall exacerbation (0.66 versus 0.47), severe exacerbation (0.44 versus 0.18) and exacerbation that resulted in hospitalisation (0.41 versus 0.16). Across regions and hospital tiers, the rates of overall exacerbation and exacerbations that resulted in hospitalisation were highest in patients with very severe COPD (based on the severity of airflow limitation or GOLD 2017 combined assessment). Strong predictors of exacerbation included demographic and clinical characteristics, modified Medical Research Council scores, mucus purulence, exacerbation history and the use of maintenance mucolytic treatment.

CONCLUSION

COPD exacerbation rates varied across regions and were higher in secondary compared with tertiary hospitals in China. Understanding the factors associated with COPD exacerbation may facilitate improved management of COPD exacerbations in China.

REGISTRATION

The trial was registered on 20 March 2017 (ClinicalTrials.gov: NCT03131362; https://clinicaltrials.gov/ct2/show/NCT03131362).

PLAIN LANGUAGE SUMMARY

Exacerbations in patients with chronic obstructive pulmonary disease in ChinaBackground: Chronic obstructive pulmonary disease (COPD) causes progressive and irreversible airflow limitation. As the disease progresses, patients often experience a flare up of symptoms referred to as an exacerbation. There is inadequate management of COPD in China and, therefore, there is a need to improve care and outcomes for patients across the country.Objective: This study aimed to generate reliable information on exacerbations among Chinese patients with COPD to help inform future management strategies.Study design and methods: Patients (aged ⩾ 40 years) were enrolled from 25 secondary and 25 tertiary hospitals across six regions of China. Physicians collected data over 1 year during routine outpatient visits.Results: There were more patients who experienced an exacerbation in secondary versus tertiary hospitals (59% versus 40%) and in rural versus urban areas (53% versus 46%). Patients in different geographic regions experienced varying frequencies of exacerbations over 1 year. Compared with patients from tertiary hospitals, patients from secondary hospitals experienced exacerbations (including exacerbations that were severe and those that resulted in hospitalisation) at a higher frequency over 1 year. Patients with very severe disease experienced exacerbations (including exacerbations that resulted in hospitalisation) at the highest frequency over 1 year, regardless of the patient's geographic region or hospital tier. Patients who had certain characteristics and symptoms, had exacerbation(s) over the previous year, or received medication that aids in the clearance of mucus were more likely to experience exacerbations.Conclusion: The frequency of exacerbations among Chinese patients with COPD varied between patients living in different geographic regions and between patients presenting to different hospital tiers. Understanding the factors related to the occurrence of an exacerbation may help physicians better manage the disease.

COPD-Related Fatigue: A Scoping Review

Millions of people worldwide have chronic obstructive pulmonary disease (COPD), and one of the most common and troublesome symptoms that must be managed is fatigue. While there are existing interventions to address COPD-related fatigue, not all patients experience benefit. A better understanding of the factors associated with COPD-fatigue could elucidate new approaches to address COPD-related fatigue, thereby offering relief to a greater number of patients. The purpose of this review was to identify the physiologic, psychologic, and situational factors associated with COPD-related fatigue. A total of four databases, PubMed, CINAHL, Scopus, and Google Scholar, were searched. Those that were peer reviewed, in English, and published between 2000 and 2021, were included in the review. A total of 25 articles were included in this scoping review. The following factors were related to fatigue in COPD: dyspnea, pain, anxiety, depression, and sleep. Fatigue is a debilitating symptom with factors influential to the symptom and outcomes. Research is indicated to explore targeted and personalized interventions addressing the factors related to fatigue to mitigate this widespread symptom.

Improving rural White men's attitudes toward clinical trial messaging and participation: effects of framing, exemplars and trust

This study examined whether framing, exemplar presence and exemplar race in social media news posts influence rural White men's perceptions, attitudes and behavioral intentions toward clinical trial participation, and if so, how individual trust in doctors moderates the effects of these three factors. An experiment with a 2 within (framing: cognitive versus psychological barriers) × 2 within (exemplar: present versus absent) × 2 between (exemplar race: White versus Black) subjects mixed factorial design was conducted among rural White men (N = 208). Twelve social media news posts about clinical trial participation were created for the experiment. Results revealed that respondents had greater behavioral intentions to participate in clinical trials after seeing posts with exemplars present (versus absent). When news posts addressed cognitive barriers (e.g. lacking knowledge about the value of clinical trials), the presence of exemplars enhanced perceived self-efficacy to participate in clinical trials. Participants with lower trust in doctors reported more favorable attitudes to posts with exemplars, and the posts with Black exemplars were perceived as more effective (approaching statistical significance). When communicating about clinical trials to rural White men, health professionals should consider including exemplars and addressing cognitive barriers to participation.

Disparities in Disease Burden and Treatment of Patients Asthma and Chronic Obstructive Pulmonary Disease

Lung health reflects the inequities of our society. Asthma and chronic obstructive pulmonary disease are 2 lung conditions commonly treated in general clinical practice; each imposes a disproportionate burden on disadvantaged patients. Numerous factors mediate disparities in lung health, including air pollution, allergen exposures, tobacco, and respiratory infections. Members of racial/ethnic minorities and those of low socioeconomic status also have inferior access to high-quality medical care, compounding disparities in disease burden. Physicians can work against disparities in their practice, but wide-ranging policy reforms to achieve better air quality, housing, workplace safety, and healthcare for all are needed to achieve equity in lung health.

Effect of chronic lung diseases on mortality of prevariant COVID-19 pneumonia patients

Background

The aim of the study is to assess the effect of chronic lung disease on mortality in patients hospitalized with the diagnosis of prevariant COVID-19 Pneumonia compared to patients without chronic lung disease.

Research design and methods

A cohort of 1,549 patients admitted to the pandemic clinic with a COVID-19 Pneumonia diagnosis was analyzed. Group 1 and Group 2 were compared in terms of the treatment they received, admission to intensive care, mortality and follow-up parameters.

Results

The patient group with COVID-19 and lung disease consisted of 231 participants (14.91%) (Group 1). The patient group with COVID-19 but without lung disease had 1,318 participants (85.19%). Group 1 cases were found to receive more oxygen therapy and mechanical ventilation than Group 2 cases (p ≤ 0.001), Following univariate and multiple logistic regression analyses, it was determined that patients with chronic lung disease had a 25.76% higher mortality risk [OR: 25.763, 95% CI (Lower-Upper) (2.445–271.465), p = 0.007].

Conclusion

It was found that chronic lung disease contributed significantly to mortality in this study. Among chronic lung diseases, Chronic Obstructive Pulmonary Disease (COPD), lung cancer and interstitial lung diseases (ILDs) were shown to be more effective than other chronic lung diseases in patients with prevariant COVİD-19 population.

Study of the dermal anti-inflammatory, antioxidant, and analgesic activity of pinostrobin

Pinostrobin is a flavanone isolated from Renealmia alpinia (Rottb.) Maas, which is used to treat painful diseases and ailments; indigenous peoples use it as plasters. Different plant species have been reported as a source of this flavonoid, among which are: Boesenbergia rotunda, Cajanus cajan, Piper ecuadorense, Piper hispidum, Teloxys graveolens, Kaempferia pandurata, among others.

Pinostrobin expresses potentially useful biological activities such as antioxidant, analgesic, and dermal anti-inflammatory, at low levels nonetheless due to its low solubility. The formation of inclusion complexes deems a good strategy to improve the pharmacologic effects of many substances.

In the present work, we evaluated the dermal toxicity, analgesic and dermal anti-inflammatory activity of pinostrobin included in cyclodextrins, to improve those effects on experimental animals. To include pinostrobin, we used two of beta cyclodextrin (βCD) and hydroxypropil beta cyclodextrin (HPβCD) complexes using two methods developed by Benesi-Hildebrand and Higuchi-Connors. Dermal anti-inflammatory activity was evaluated in experimental mice by inhibiting the edema generated by 12-O-tetradecanoylforbol-13-acetate (TPA). Analgesic activity was evaluated by inducing chemical pain by means of a Siegmund test. Antioxidant activities were measured with two in vitro tests.

Analgesic and dermal anti-inflammatory activities of pinostrobin, as included in control and experimental complexes, showed comparatively better effects than pinostrobin without inclusion complexes. Our results indicate that both beta cyclodextrin (βCD) and hydroxypropyl beta cyclodextrin (HPβCD) enhance the different effects of pinostrobin, which may indicate greater bioavailability.

Factors Associated With Geographic Disparities in Gastrointestinal Cancer Mortality in the United States

BACKGROUND & AIMS

Significant geographic variability in gastrointestinal (GI) cancer-related death has been reported in the United States. We aimed to evaluate both modifiable and nonmodifiable factors associated with intercounty differences in mortality due to GI cancer.

METHODS

Data from the Centers for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research platform were used to calculate county-level mortality from esophageal, gastric, pancreatic, and colorectal cancers. Multivariable linear regression models were fit to adjust for county-level covariables, considering both patient (eg, sex, race, obesity, diabetes, alcohol, and smoking) and structural factors (eg, specialist density, poverty, insurance prevalence, and colon cancer screening prevalence). Intercounty variability in GI cancer-related mortality explained by these covariables was expressed as the multivariable model R².

RESULTS

There were significant geographic disparities in GI cancer-related county-level mortality across the US from 2010-2019 with the ratio of mortality between 90th and 10th percentile counties ranging from 1.5 (pancreatic) to 2.1 (gastric cancer). Counties with the highest 5% mortality rates for gastric, pancreatic, and colorectal cancer were primarily in the Southeastern United States. Multivariable models explained 43%, 61%, 14%, and 39% of the intercounty variability in mortality rates for esophageal, gastric, pancreatic, and colorectal cancer, respectively. Cigarette smoking and rural residence (independent of specialist density) were most strongly associated with GI cancer-related mortality.

CONCLUSIONS

Both patient and structural factors contribute to significant geographic differences in mortality from GI cancers. Our findings support continued public health efforts to reduce smoking use and improve care for rural patients, which may contribute to a reduction in disparities in GI cancer-related death.

Trends in Endogenous Endophthalmitis in Rural and Urban Settings in the United States

PURPOSE

The objective of this study is to explore and compare trends in urban and rural cases of endogenous endophthalmitis (EE) in the United States.

METHODS

This study utilizes data from the 2002-2014 National Inpatient Sample (NIS) Database. Disease diagnoses and procedures were identified using codes from the International Classification of Diseases, Ninth Revision (ICD-9). Cases of EE were defined as cases of endophthalmitis in the setting of bacteremia or candidemia without a recent history of ocular trauma. The NIS Database defines urban and rural hospitals based on the hospital county's population statistics. Statistical analysis was performed using IBM SPSS 23.

RESULTS

We identified 8255 cases of EE. Of these cases, 523 (6.3%) occurred in rural areas; 7733 (93.7%) occurred in urban areas. Of the cases of EE, 7692 (93.2%) were bacterial EE, 412 (5.0%) were candida EE, and 151 (1.8%) were mixed EE. Candida EE was observed in 1.7% of rural cases and 5.2% of urban cases (p < .001). Pars plana vitrectomies were performed more often in urban hospitals than in rural hospitals (11.5% vs. 2.9%; p < .001).

CONCLUSION

Endogenous endophthalmitis remains a rare but devastating ocular infection. In this study, we have demonstrated that there are important differences in cases of EE that present to urban and rural hospitals. Future investigations into these differences in patient demographics, source/systemic infections, and hospital courses may allow clinicians and hospitals to develop a more targeted approach to treating EE based on the type of community from which the patient presents.

The Town-Level Prevalence of Chronic Lung Conditions and Death From COVID-19 Among Older Adults in Connecticut and Rhode Island

Introduction

As of November 2021, older adults (aged ≥65 y) accounted for 81% of all deaths from COVID-19 in the US. Chronic lung diseases increase the risk for severe COVID-19 illness and death. The aim of this research was to examine the association between town-level rates of asthma and chronic obstructive pulmonary disease (COPD) and deaths from COVID-19 in 208 towns in Connecticut and Rhode Island.

Methods

We conducted a multistep analysis to examine the association between town-level chronic lung conditions and death from COVID-19. Pairwise correlations were estimated and bivariate maps were created to assess the relationship between COVID-19 deaths per 100,000 people and 1) asthma prevalence and 2) COPD prevalence among adults aged 65 years or older. We used multiple linear regression models to examine whether chronic lung conditions and other town-level factors were associated with COVID-19 death rates in Connecticut and Rhode Island.

Results

Initial bivariate correlation and mapping analyses suggested positive correlations between asthma and COPD prevalence and COVID-19 death rates. However, after controlling for town-level factors associated with chronic lung conditions and COVID-19 death rates, multiple linear regression models did not support an association, but town-level factors (African American race and Hispanic ethnicity, age ≥65 y, and low educational attainment) were significant predictors of COVID-19 death rates.

Conclusion

We found significant associations between town-level factors and COVID-19, adding to the current understanding of the impact of social determinants of health on outcomes.

PLACES: Local Data for Better Health

Local-level data on the health of populations are important to inform and drive effective and efficient actions to improve health, but such data are often expensive to collect and thus rare. Population Level Analysis and Community EStimates (PLACES) (www.cdc.gov/places/), a collaboration between the Centers for Disease Control and Prevention (CDC), the Robert Wood Johnson Foundation, and the CDC Foundation, provides model-based estimates for 29 measures among all counties and most incorporated and census-designated places, census tracts, and ZIP Code tabulation areas across the US. PLACES allows local health departments and others to better understand the burden and geographic distribution of chronic disease-related outcomes in their areas regardless of population size and urban-rural status and assists them in planning public health interventions. Online resources allow users to visually explore health estimates geographically, compare estimates, and download data for further use and exploration. By understanding the PLACES overall approach and using the easy-to-use PLACES applications, practitioners, policy makers, and others can enhance their efforts to improve public health, including informing prevention activities, programs, and policies; identifying priority health risk behaviors for action; prioritizing investments to areas with the biggest gaps or inequities; and establishing key health objectives to achieve community health and health equity.

Proteomic Network Analysis of Bronchoalveolar Lavage Fluid in Ex-Smokers to Discover Implicated Protein Targets and Novel Drug Treatments for Chronic Obstructive Pulmonary Disease

Bronchoalveolar lavage of the epithelial lining fluid (BALF) can sample the profound changes in the airway lumen milieu prevalent in chronic obstructive pulmonary disease (COPD). We compared the BALF proteome of ex-smokers with moderate COPD who are not in exacerbation status to non-smoking healthy control subjects and applied proteome-scale translational bioinformatics approaches to identify potential therapeutic protein targets and drugs that modulate these proteins for the treatment of COPD. Proteomic profiles of BALF were obtained from (1) never-smoker control subjects with normal lung function (n = 10) or (2) individuals with stable moderate (GOLD stage 2, FEV1 50−80% predicted, FEV1/FVC < 0.70) COPD who were ex-smokers for at least 1 year (n = 10). After identifying potential crucial hub proteins, drug−proteome interaction signatures were ranked by the computational analysis of novel drug opportunities (CANDO) platform for multiscale therapeutic discovery to identify potentially repurposable drugs. Subsequently, a literature-based knowledge graph was utilized to rank combinations of drugs that most likely ameliorate inflammatory processes. Proteomic network analysis demonstrated that 233 of the >1800 proteins identified in the BALF were significantly differentially expressed in COPD versus control. Functional annotation of the differentially expressed proteins was used to detail canonical pathways containing the differential expressed proteins. Topological network analysis demonstrated that four putative proteins act as central node proteins in COPD. The drugs with the most similar interaction signatures to approved COPD drugs were extracted with the CANDO platform. The drugs identified using CANDO were subsequently analyzed using a knowledge-based technique to determine an optimal two-drug combination that had the most appropriate effect on the central node proteins. Network analysis of the BALF proteome identified critical targets that have critical roles in modulating COPD pathogenesis, for which we identified several drugs that could be repurposed to treat COPD using a multiscale shotgun drug discovery approach.

Severity distribution and treatment of chronic obstructive pulmonary disease in China: baseline results of an observational study

Background

Chronic obstructive pulmonary disease (COPD) receives low awareness and is undertreated in China. Understanding the burden and treatment of COPD across the nation is important for improving quality of care for this disease. This study aims to reveal the current situation of COPD severity distribution and management across China.

Methods

Baseline data from REALizing and Improving Management of Stable COPD in China, a multicentre, prospective, longitudinal, observational study, were analysed. Patients diagnosed with COPD as per Global Initiative for Chronic Obstructive Lung Disease 2016 (GOLD 2016) criteria were enrolled from 50 randomly selected hospitals (tertiary, 25; secondary, 25) across six geographical regions. Data were collected in routine clinical settings.

Results

Between 15 December 2017 and 6 August 2020, 5013 patients were enrolled and 4978 included in the full analysis set. Of these, 2459 (49.4%) reported ≥ 1 exacerbation within 12 months prior to study enrolment, with a mean annual rate of 0.9/patient, including 0.2/patient and 0.5/patient leading to emergency room visits and hospitalisation, respectively. Spirometry graded 458 (10.1%), 1886 (41.7%), 1558 (34.5%), and 616 (13.6%) were GOLD stage I–IV, and 536 (11.4%), 1034 (22.0%), 563 (12.0%), and 2566 (54.6%) were classified as GOLD 2016 Group A–D, respectively, without evident regional variations. Inhaled corticosteroids plus long-acting beta₂-agonist (ICS/LABA, 1316 [26.4%]), ICS/LABA plus long-acting muscarinic antagonist (ICS/LABA + LAMA, 871 [17.5%]), and LAMA (754 [15.1%]) were prescribed at high rates across all groups and regions. Medications not recommended by GOLD were commonly prescribed (TCM, 578 [11.6%]; others, 951 [19.1%]), and 681 (13.7%) were not given ICS or long-acting bronchodilators.

Conclusions

Disease burden among Chinese COPD outpatients is high. Improved guideline adherence for COPD treatment is needed.

Trial registration ClinicalTrials.gov identifier, NCT03131362.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12931-022-02021-w.

Exploring community members' perceptions to adopt a Tele-COPD program in rural counties

Background

Patients diagnosed with COPD residing in rural areas report a lower quality of life. Telehealth addresses geographic barriers by offering routine, technology-based visits, and remote patient monitoring.

Objective

The study objective was to explore adoption perceptions of a tele-COPD program among community members in rural Western North Carolina (WNC) counties.

Methods

A convenience sample of 17 community members were recruited to participate in one of five 45-min focus groups. Before the focus group, all participants completed a brief demographic survey. Focus groups were digitally recorded, transcribed verbatim, imported into MAXQDA v10, and analyzed thematically using established qualitative coding procedures. SPSS v22 was used to calculate descriptive statistics.

Results

Participants were primarily Non-Hispanic White (100%), male (59%), insured (100%), and had at least a high school education (80%). Only 25% of participants had any prior knowledge of telehealth programs. The majority (94%) of participants expressed interest in receiving a tele-COPD program due to convenience factors. Yet, most participants expressed a lack of interest and comfort in using Internet-capable devices (e.g., mobile devices, tablets, computers). Participants noted that to be successful, telehealth visits must be described and shown to them by their own provider or other trusted individual(s), such as a pharmacist. Privacy and cost were also expressed as telehealth concerns.

Conclusion

Interest in a tele-COPD program was high among community residents in rural WNC. However, to increase patient willingness to adopt a tele-COPD program, patients' providers must overcome challenges, such as patients' awareness and knowledge of telehealth, privacy and cost concerns, and access to and comfort with using new technologies. Pharmacists may mitigate these challenges by increasing patients' trust and comfort with telehealth programs.

•

Telehealth offers video-based visits and remote patient monitoring in rural areas.

•

Participants expressed concerns about privacy, cost, and using Internet-capable devices.

•

Participants stated successful, telehealth visits must be described and shown by provider(s) or other trusted individual(s).

•

Pharmacists may mitigate these concerns by increasing patients' trust and comfort with telehealth programs.

Clinical Implications of Bronchodilator Testing: Diagnosing and Differentiating COPD and Asthma-COPD Overlap

BACKGROUND

Bronchodilation testing is an important component of spirometry testing, and omitting this procedure has potential clinical implications toward diagnosing respiratory diseases. We aimed to estimate the impact of bronchodilator testing in accurately diagnosing COPD and differentiating COPD from asthma-COPD overlap (ACO).

METHODS

The National Health and Nutrition Examination Survey data were analyzed from 2007-2012. Airflow limitation was defined by FEV₁/FVC < 0.7. Subjects with pre-bronchodilator airflow limitation were classified into pre-but-not-post-bronchodilator airflow limitation and post-bronchodilator airflow limitation groups. Spirometry-confirmed COPD was defined by persistent airflow limitation on post-bronchodilator spirometry. The American Thoracic Society (ATS) and the Spanish Society of Pneumology and Thoracic Surgery (SEPAR) definitions were used to identify possible ACO subjects.

RESULTS

We identified 11,763 subjects ≥ 40 y of age eligible for spirometry; 625 of them had a pre-bronchodilator FEV₁/FVC < 0.7 and completed post-bronchodilator spirometry that met ATS spirometry quality standards. A total of 244 (39%) of these subjects had only pre-not-post-bronchodilator airflow limitation, thereby not meeting the definition of spirometrically confirmed COPD. The prevalence of ACO was 7.6% using the modified ATS definition and 19.8% using the modified SEPAR criteria. When bronchodilator testing-based criteria were excluded from ATS and SEPAR definitions, the number of ACO subjects decreased by 39.3% and 12.3%, respectively.

CONCLUSIONS

Spirometry with bronchodilation is an important element in the accurate diagnosis of ACO and COPD. Spirometry performed without bronchodilator testing may lead to an estimated misclassification of ACO by 7.6% to 19.8% and overdiagnosis of COPD by 39%.

Recruitment and engagement in disease self-management programs: Special concerns for rural residents reporting depression and/or anxiety

•

Poorer health outcomes are correlated with depression/anxiety in a rural population.

•

Electronic modes of recruitment engage those reporting depression/anxiety into CDSME.

•

CDSME increases patient activation regardless of history of depression/anxiety.

Chronic disease self-management education (CDSME) programs benefit individuals with chronic diseases, including mental health conditions, by improving health-related outcomes and increasing engagement with the health care system. Recruiting individuals with a history of mental health conditions to participate in CDSME is challenging, particularly in rural, underserved areas. Hence, it is important to understand factors associated with the presence of mental health conditions, and impacts of CDSME on patient engagement. This project identifies individual and program-level characteristics, as well as recruitment characteristics, associated with reporting a history of depression and/or anxiety. It also assesses factors related to program engagement and the relationship between completing CDSME and patient activation. Data were collected during CDSME workshops offered in 2019 in a rural region of New York. Of the 421 enrollees who completed survey instruments, 162 reported a history of depression and/or anxiety. Univariate analyses indicated that those reporting a history of depression and/or anxiety were younger, female, in poorer health, had more comorbidities, were Medicaid beneficiaries, and had lower patient activation scores. They also heard about and signed up for the workshop through the internet at higher rates than those not reporting a history of depression and/or anxiety. Multivariable logistic regression modeling indicated age, self-rated health, and number of comorbidities were independent predictors of reporting a history of depression and/or anxiety. Among CDSME completers, patient activation significantly improved regardless of history of depression and/or anxiety. Engaging individuals with mental health conditions in CDSME requires a multimodal recruitment strategy incorporating electronic marketing and registration.

Prevalence of Pulmonary Embolism and Deep Venous Thromboembolism in Patients With Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-Analysis

Background

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) increases the risk of pulmonary embolism (PE) and deep venous thrombosis (DVT). AECOPD combined with PE and DVT poses challenges for treatment and management. This necessitates prevention and management to estimate the overall prevalence of PE and DVT among patients with AECOPD and to identify the risk factors.

Methods

We searched the PubMed, Embase, and Cochrane Library databases from their inception to January 9, 2021 and extracted the data from the included studies. The risk of bias was assessed for each study. We separately calculated the prevalence of PE and DVT in patients with AECOPD. Subgroup analysis and meta-regression analyses were performed to determine the sources of heterogeneity. Furthermore, we assessed the publication bias.

Results

The meta-analysis included 20 studies involving 5,854 people. The overall prevalence of PE and DVT among patients with AECOPD was 11% (95% CI: 0.06–0.17) and 9% (95% CI: 0.06–0.12), respectively. Subgroup analysis demonstrated that the prevalence of PE among patients with AECOPD was 12, 2, 7, and 16% in the European, South-East Asia, Western Pacific, and Eastern Mediterranean regions, respectively, and the DVT was 10, 9, 9, and 4%, respectively. The prevalence of PE among patients with AECOPD aged ≥ 70 and <70 years old was 6 and 15%, respectively, and the DVT was 8 and 9%, respectively. The prevalence of PE among patients with AECOPD diagnosed within 48 h and other times (beyond 48 h or not mentioned) was 16 and 6%, respectively, and DVT was 10 and 7%, respectively.

Conclusion

The pooled prevalence of PE and DVT among patients with AECOPD was insignificantly different between the different age groups and the WHO regions. However, the early diagnosis was associated with a higher prevalence of PE. Clinicians and the public need to further improve the awareness of prevention and management for PE and DVT among patients with AECOPD.

Systematic Review Registration

PROSPERO, identifier CRD42021260827.

Mississippi CHAMPS: Decreasing Racial Inequities in Breastfeeding

Mississippi CHAMPS addressed racial inequities in breastfeeding by implementing community and hospital-based practice changes in accordance with the BFHI and by parallel community work.

The Association of Health-Related Factors with Leisure-Time Physical Activity among Adults with COPD: A Cross-Sectional Analysis

This study aimed to examine the association of health attitudes, health appraisals and affective experience to leisure-time physical activity in adults with chronic obstructive pulmonary disease (COPD). Cross-sectional analyses were conducted with a sample of 274 adults with COPD drawn from the second wave of the Midlife in the United States (MIDUS 2) Study. Chi-square analyses and independent t-tests were used to test the differences between physically active and inactive COPD patients (active group versus inactive group) for all study variables. Multiple logistic regression was used to examine the association of each study variable with leisure-time physical activity. The results showed that there were significant differences between the active and inactive groups in terms of age, education, functional limitations, health attitudes, health appraisals and affective experience. After controlling for socio-demographic variables and functional limitations, beliefs about the importance of physical fitness and strength for a good life and comparative health appraisals were significantly related to physical activity. However, neither negative nor positive affect was associated with physical activity status. Modifiable factors, such as health attitudes toward physical fitness and strength, as well as health appraisals, should be considered for developing effective physical activity promotion interventions among COPD patients.