THE DIMENSIONS OF THE CHRONIC RESPIRATORY DISEASE PROBLEM

Transcription

1 THE DIMENSIONS OF THE CHRONIC RESPIRATORY DISEASE PROBLEM Harry E. Walkup, M.D., and Eleanor C. Connolly, M.P.H. CHIIONIC disease, with the exception of pulmonary tuberculosis, has until recently been one of the most neglected disease categories in the modern practice of medicine.j To recognize the accuracy of this statement one has only to examine the evolution of our knowledge of bronchogenic carcinoma and other major chronic diseases. As late as three or four decades ago the physician and pathologist considered bronchogenic carcinoma a rare entity and failed to recognize its primary site or pulmonary origin. Instead, it was described as arising in the adjacent mediastinal structures, or was thought to be metastasized from what was later found to be its own metastases. Another example one might mention to illustrate this point would be pulmonary emphysema. Fifteen to twenty years ago emphysema was known as a clinical entity, but for practical purposes individuals were classified as those in whom the condition was marked by severe disabling symptoms and signs, and those in whom it was not. Various gross classifications were proposed, usually based on the posture of advanced emphysema patients - now known to be the effect rather than the cause and certain roentgenographic or gross anatomical manifestations such as the presence of blebs or bullae or the absence of vascular markings, the socalled "vanishing lung." It has been only in the past decade that the pathologists and anatomists have focused their attention on the significance of the primary lobule as the anatomical unit of the lung of particular importance in emphysema. and have offered a reasonable scientific classification of the disease. Histopathologic studies, coupled with recent advances in technics for testing pulmonary function, have called attention to the fact that emphysema is truly a chronic progressive disease, but that in many instances it may be arrested or its progression delayed, if detected early and proper measures are taken. Bronchial asthma, on the other hand, represents the one chronic disease concerning which we have accumulated detailed clinical information. This is largely due to the early discovery of bronchodilating hormones and drugs, such as epinephrine and ephedrine, for the relief of patients, and which have made possible laboratory and clinical investigation. This factor, which also stimulated and paralleled the advances made in the field of allergy during the past few decades, was responsible for our more extensive clinical knowledge of this disorder. However, paradoxical as it may seem, less statistical information is available on bronchospasm and asthma than for many of the other common chronic diseases. Chronic bronchitis, prior to the diagnostic advances of the past eight or nine years, represented one of the most perplexing diagnostic and clinical classification problems in the entire chronic disease field. As a surgeon, I can state frankly that for years the thoracic surgeons in this country and MARCH,

2 Table 1-Respiratory Conditions Reported in National Health Survey, United States, 1960 Bed Disability Days per Person with Condition Condition Total per Year Persons with asthmahay fever 11,717, Persons with chronic bronchitis 1,913, Persons with other chronic conditions (excluding sinusitis) 2,174, Number of acute coinditions 196,276, * * Per person in population. 2 abroad removed areas from the more dependent portions of the lungs-basal segments, lingula, and right middle lobe -of patients believed to have cylindrical bronchiectasis when bronchographic media, employing the then existing radiographic technics, demonstrated the bronchi in such areas as adynamic ectatic structures. Many of these patients had chronic bronchitis rather than cylindrical bronchiectasis. During that period cinefluorographic and image intensification radiographic technics had not been perfected, and the presence of chronic bronchitis in other areas of the lungs was not demonstrated, or at least not recognized. It was only after the technological advances in the field of roentgenography and recognition of the poor results from surgery in the socalled cylindrical bronchiectasis patients that attention was called to the true nature of the malady being dealt with. Before leaving this part of the discussion the chronic infectious diseases, other than tuberculosis, should also be mentioned. These diseases have also been neglected until recent years, due to our insufficient knowledge about them. If it were possible to obtain accurate data on the patients who were hospitalized for long periods with a diagnosis of pulmonary tuberculosis during the past three decades, but who actually had pulmonary fungus disease, particularly histoplasmosis and blastomycosis, unclassified mycobacterial disease, pulmonary disorders caused by nocardia, and several other less common chronic infectious pulmonary diseases, the result would be interesting indeed. As Goethe once remarked, "What one knows, one sees." Consequently, it was only after basic scientific facts about these diseases became known that efficient laboratory and clinical methods for their diagnosis could be established, differentiating them from pulmonary tuberculosis. I am certain, however, that the statistical data of yesteryear still include them under the latter disease category. With this brief clinical introduction to the chronic disease problem, the figures to be presented should be more meaningful. It is my impression, after taking the clinical factors into consideration and evaluating the qualitative technics employed in many instances to obtain the statistical data, that available figures tend to underestimate the over-all problem. However, all things considered, statistical data do serve as a reliable guide to a better understanding of the dimensions of the chronic disease problem. The remainder of this presentation will be concerned with the available data on prevalence, bed disability, hospital utilization, medical attention, disability benefits granted, and mortality in the United States from the more common chronic diseases. Both Tables 1 and 2 show the preva- VOL. 53, NO. 3, A.J.P.H.

3 CHRONIC RESPIRATORY DISEASES lence of chronic disease in this country, according to the National Health Survey. Data are derived from interviews of a sample of the noninstitutionalized population (except for the tuberculosis estimate, which is from tuberculosis case register data and does not include numerous persons with inactive disease who are no longer being followed by health departments). The number of acute conditions is included in Table 1 to illustrate the fact that, although acute conditions are much more prevalent than chronic, chronic diseases cause more days of bed disability a year for the person affected than do the acute. It should be noted that the specific chronic conditions listed are equivalent to the number of persons affected, while acute conditions, which may have affected some persons more than once, represent incidence of episodes. (Although the figures for specific chronic conditions represent prevalence of persons with those conditions, the total of persons with some type of chronic disease cannot be obtained by addition, due to the fact that an individual can have more than one condition.) The high rate of bed disability days for "other chronic conditions" may be due to inclusion in this group of such disease entities as emphysemra and silicosis. Chronic sinusitis, which is excluded from the figures in this presentation, affected over ten million persons in In Table 2 we see that a high percentage of the persons with a chronic condition had been medically attended for the condition at some time. The parlicularly high per cent with activity limitation among those with "other chronic conditions" may again be due to the inclusion in this group of such crippling diseases as emphysema. ("Limited in activity" refers to limitation in the number of hours a person can work or go to school, in the amount or kind of work or schooling, or limitation in ability to participate in sports, recreational, or other activity.) The data in Table 3 have been selected to depict the number and per cent distribution of deaths from some of the common chronic diseases in the year The per cent change between 1954 and 1959 is included to bring the changing picture into proper perspective. It is interesting to note the significance of the trend upward for emphysema and neoplasms of the lung. The per cent increase for neoplasms is Table 2-Chronic Respiratory Conditions Reported in National Health Survey, United States, 1960 Per cent with Per cent Ever Any Degree Medically of Activity Condition Number Attended Limitation Asthma-hay fever 11,717, Bronchitis 1,913, Tuberculosis 330,000* N.A. Other chronic conditions 2,174,000t * Not a National Health Survey estimate; includes only persons under public health supervision, including 60,000 in hospitals. t Excludes sinusitis. MARCH,

4 Table 3-Deaths from Specific Chronic Respiratory Diseases, United States, 1959 Per cent Deaths Per cent Change Cause of Death 1959 Distribution Deaths from all causes 1,656, Asthma 4, Bronchitis 2, Emphysema 7, Malignant neoplasms of system 38, Trachea, bronchus, and lung specified as primary 17, Tuberculosis of system 10, Source: National Vital Statistics Division, Washington, D. C. less than for emphysema, but is on a far larger base, so that in terms of numbers the increase in neoplasms is more significant than that for emphysema. The increase in deaths from bronchitis, emphysema, and malignant neoplasms of the system more than compensates for the decrease in deaths from tuberculosis and asthma, so that there is a net increase in deaths from 1954 to 1959 of 18.7 per cent for this group of chronic diseases. The National Disease and Therapeutic Index provides data on private patient contacts with physicians (Table 4). The selected chronic diseases shown in Table 4 account for a relatively small per cent of all visits to doctors, who see far more acute episodes. Although not shown in the table, the entire group, both acute and chronic, accounted for 15 per cent of the total visits for the one-year period. Pregnancies, inoculations, and routine physical examinations were not included in the total of visits, in order that this study would be comparable with the hospital study shown in Table 5, which was confined to disease and injury diagnoses. Chronic diseases account for less of a burden on the general hospital than do the acute (Table 5). For instance, pneumonia patients, who are not shown here, accounted for 4 per cent of all patients discharged during the sixmonth period. These data do not reflect the true proportion of patients hospitalized with tuberculosis, since most Table 4-Private Patient Contacts with Physicians Because of Specific Chronic Respiratory Diseases, April, March, 1962, United States Number Per cent Diagnosis of Visits Distribution All visits* 799,927, Asthma 9,132, Bronchitis 12,993, Malignant neoplasms of system 997, Tuberculosis of system 831, * Excludes pregnancies, inoculations, routine physicals, and so forth. Source: National Disease and Therapeutic Index, Flourtown, Pa. 4 VOL. 53, NO. 3. A.J.P.H.

5 CHRONIC RESPIRATORY DISEASES Table 5-Specific Chronic Respiratory Diseases in Patients Discharged from 132 General Hospitals, United States, January-June, 1960 Number of Per cent Primary Diagnosis Patients Distribution Total discharges* 405, Asthma 1, Bronchitis 2, Emphysema Malignant neoplasms of system 1, Tuberculosis of system * Exclu(les pregnancies, inoculations, and so forth. Source: Commission on Professional and Hospital Activities, Ann Arbor, Mich. tuberculosis patients go to special hospitals. Chronic diseases are most important in terms of disability benefits granted under the disability program of the Bureau of Old-Age and Survivors Insurance. Such benefits are granted only to those persons whose condition is expected to result in death or be of longcontinued and indefinite duration. The two diseases which account for a significant proportion of all disabilities for which benefits were granted under this program during 1960 are emphysema and tuberculosis. Although not shown in Table 6, emphysema was the second most frequently reported single disease for which such benefits were granted in In conclusion, one might say that the dimensions of the chronic disease problem are significant, and that the perspective from which the problem is viewed determines the degree of this significance. As we have said, the urgency of the acute episode means that such cases are seen in far greater numbers by the private physician and the hospital than are cases of chronic disease, such as asthma or chronic bronchitis. Yet chronic disease is far more serious for the patient affected, in terms of duration, confinement, and possible serious incapacitation. Even in death statistics, chronic diseases are presented in a minor role. An acute disease, pneumonia, remains a leading cause of death, being responsible for 52,000 deaths in 1959; it is not as readily apparent that malignant neoplasms of the system, causing close to 40,000 deaths a year, would also outrank many causes of death if ranked as a single disease entity instead of with neoplasms of all other sites, as is the traditional practice. Nor is it appreciated that the combined total of deaths from malignant neoplasms of the system, asthma, bronchitis, emphysema, and tuberculosis exceeded those from pneumonia by over 10,000 in Although we do not know the total number of persons with chronic respira- Table 6-Workers Granted Disability Benefits in the United States in 1960 Because of Specific Chronic Diseases Workers Granted Per cent Primary Diagnosis Benefits Distribution Total disabilities 179, Asthma 27 Bronchitis Emphysema 12, Malignant neoplasms of system 4, Tuberculosis of system 7, Source: Bureau of Old-Age and Survivors Insurance. MARCH,

6 tory disease, we know that they can be counted in the millions. We also know that roughly 10 per cent of these people, and possibly a higher proportion, are limited in some of their usual activities because of their disorder. Most significant, we know that as a cause of disability severe enough to terminate the working career, chronic diseases, particularly emphysema and tuberculosis, are extremely important. Although the per cent of workers granted disability benefits due to tuberculosis may decrease in future years from the 4.4 per cent they accounted for in 1960, there is no reason to believe that the proportion of disabled workers with emphysema or other chronic ailments will decrease. Indeed, if atmospheric pollutants and certain habits of man are factors in the development and exacerbation of lung disease, there is good reason to think that certain diseases, such as emphysema, will attain more prominence in disability statistics in the future. ACKNOWLEDGMENT is made to Miss Mae Brautigam for her statistical contribution to this paper. Dr. Walkup is director and Miss Connolly is consultant, Division of Research and Statistics, National Tuberculosis Association, New York, N. Y. 6 VOL. 53, NO. 3. A.J.P.H.