American Thoracic Society (ATS) Perspective

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1 National Surveillance System for Chronic Lung Disease (CLD): American Thoracic Society (ATS) Perspective Gerard J. Criner, M.D.

2 Chronic Obstructive Pulmonary Disease (COPD) l Definition: Group of chronic lung diseases that impairs airflow and makes breathing more difficult. Includes: l Emphysema (permanent destruction of lung tissue) l Chronic obstructive bronchitis (narrowed airways). l Both may occur in the same individual l Symptoms include: wheezing, chest tightness, mucus- producing cough and shortness of breath l Disease is preventable and treatable

3 COPD : The Problem l COPD is a major cause of morbidity & mortality in the U.S. and worldwide l Twelve million Americans have COPD l It is the fourth leading cause of death in the United States behind heart disease, cancer, and cerebrovascular disease l In 2005, 121,000 deaths were attributed to COPD approximately one in 20 deaths in the U.S. l Death rate in 2005 represented an 8% increase compared to death rate in year 2000

4 Percent Change in Age-Adjusted Death Rates, U.S., Proportion of 1965 Rate Coronary Heart Disease Stroke Other CVD COPD All Other Causes % 64% 35% +163% 7%

5 The Changing Face of COPD l COPD now affects more than just older Caucasian males l 70% of COPD patients are < 75 yrs old l Marked increase in numbers of woman hospitalized and dying from COPD l Marked increase in numbers of African-Americans Americans seeking emergency care and dying from COPD

6 Age-Adjusted Death Rates for COPD, U.S., Deaths per 100, White Male Black Male White Female Black Female

7 Number of Deaths x 1000 Similar Mortality Rates for Men and Women COPD Mortality by Sex United States, Men Women Year Mannino DM et al. MMWR CDC Surveill Summ. 2002;51:1-16.

8 COPD: Risks l About 75% of COPD cases are attributed to smoking l Occupation-related exposures account for between 10 and 20% of COPD cases l Genetic cause ~ 2% l Poorly controlled asthma is risk l Exposure to indoor and outdoor air pollution and second hand smoke l COPD often exists with co-morbid conditions (i.e., cardiac disease, stroke, hypertension, osteoporosis, muscle weakness or diabetes) l COPD exacerbations have profound affect on trajectory of the disease

9 COPD Exacerbations (AECOPD): The Major Complication of COPD l Sentinel morbid and mortal events in the life of a COPD patient l Following an acute exacerbation: l Most patients experience a transient or permanent decrease in QOL l May hasten a decline in lung function l Accounts for majority of 16 million COPD office visits; 672,000 hospitalizations. In 2010, COPD- related health costs were almost $50 billion l 50% of hospitalized AECOPD are readmitted within 6 months

10 Hospitalized Severe AECOPD and Mortality: Severity of AECOPD Soler-Cataluna Thorax no AECOPD 2- AECOPD ED 3- AECOPD Hosp 4- AECOPD Readmit

11 Annual Number of Admissions for AMI and AECOPD in Pennsylvania ( Number of Patients COPD AMI FY

12 Google: Heart Attack 48 million hits Reviews signs and symptoms Causes Therapies Where to get treatments

13 Google: COPD Exacerbation 165,000 hits 0.3% of Heart Attack hits Top hits review the definition and explain what term means COPD symptoms Therapies

14 Public Images of Presentations of AMI or COPD Exacerbations Heart Attack COPD Exacerbation

15 Patient Understanding, Detection, and Experience of COPD Exacerbations Patient Expressions of Exacerbations Kessler ; Chest 2006;130:133-42

16 Patients only Contact Their Doctor 18% of the Time for an Exacerbation Kessler ; Chest 2006;130:133-42

17 What are the Gaps in Current Data for CLD Surveillance to Measure Health Disparities and Quality of Care? l Improve information collection, analysis and reporting of COPD related public health monitoring l Public and medical consciousness of COPD morbidity, mortality, prevention and treatment is lower than optimum l Spirometry is under utilized to diagnose COPD l COPD related topics could be analyzed more extensively in current data and new questions added to surveys l Epidemiology of COPD will change over time (as smoking becomes less prevalent, other causes will become more apparent)

18 Proposed Solutions to Current Gaps l Maximize use of currently available data l Analyze available data relevant to COPD in existing CDC surveys (National tobacco survey) l Initiate new data collection within existing CDC surveys l Behavioral Risk Factor Survey System (BRFSS) (state-based, self-reported) l National Health and Nutrition Examination Survey (national,( combination of interviews and physical exams) l National Health Interview Survey (national, cross-sectional sectional household interview survey) l Adapt and expand CDC National Health Care Surveys collection (health care system-based surveys) l Broaden terms used to define COPD-emphysema, chronic bronchitis, bronchitis l Include questions re: occupational & environmental exposures l Include family history: genetic risks l Information about asthma

19 How Can Surveillance Data be Used to Influence Public Health Action to Improve Care Delivery and Reduce Health Disparities? l Heighten general awareness of COPD, its symptoms, and standard approaches to diagnosis, prevention and treatment l Enhance collaboration between public health tobacco control programs (national, state and local) and COPD programs l Develop National COPD Action Plan l Create and support workplace programs to reduce COPD risks

20 What Would Increase the Feasibility and Usefulness of a CLD National Surveillance System? l Develop, support and conduct research that explores the risk factors, prevention and treatment of COPD l Assess environmental risk factors for COPD in addition to smoking l Assess current healthcare practices regarding the diagnosis and treatment of COPD and its related comorbidities l Identify public health research needs for COPD Prevention

21 Features of CLD Health Surveillance that Takes Full Advantage of Technology and Informatics l Collect, analyze and report de-identified health care data from electronic health records (EHRs( EHRs) l Unified EHR definition of COPD l Collect standard demographic and clinical history information: l Age/Gender/Race/PMH l Smoking l Occupation l Spirometry l Exacerbation history: # admissions and ER/urgent visits, ICU care, ventilation l Treatment: O 2, types bronchodilators, inhaled and systemic steroids, rehabilitation, self-care programs, LVRS/transplant l Co morbidities

22 Challenges to CLD Surveillance System and How to Overcome? l Awareness of COPD prevention, diagnosis and treatment is low among medical and lay public l Collaborate with appropriate partners to heighten general awareness of COPD, its risk factors, diagnosis, prevention and treatment for the lay public l Collaborate with health professionals to communicate current standards of COPD diagnosis, prevention and treatment to clinical communities

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