Chronic Obstructive Pulmonary Disease

Transcription

1 Chronic Obstructive Pulmonary Disease Population Health Monograph

2 Contents Central Adelaide and Hills Medicare Local coordinates and delivers primary health care, on the lands and seas of the traditional custodians, the Kaurna and Peramangk people. We recognise them as the traditional custodians, and respect that Aboriginal and Torres Strait Islander people represent the continuum of the world s longest living culture, and that these historical relationships are enduring. Introduction What is COPD? Determinants and Risk Factors for COPD COPD Determinants across the Region COPD Risk Factors across the Region COPD Prevalence across the Region Hospital Admission Rates 0 2 Chronic Disease Management Continuum Primary Prevention Secondary Prevention and Early Diagnosis Tertiary Prevention - Management and Control Conclusion and Suggested Directions References Central Adelaide and Hills Medicare Local - Chronic Obstructive Pulmonary Disease Central Adelaide and Hills Medicare Local - Chronic Obstructive Pulmonary Disease

3 Introduction What is COPD? COPD is a condition that affects the respiratory and circulatory systems. It is caused by the inhalation of noxious particulates or gases which in turn stimulate an abnormal inflammatory response from the lungs. [] This inflammatory response interferes with normal breathing patterns and can be life threatening. Individuals with COPD report symptoms such as breathlessness, wheezing, tightening of the chest and difficulty performing exercise. The disease is progressive and responds poorly to treatment, although treatment can slow the disease s progression. Currently, there is no cure for COPD. COPD is a debilitating disease, that as it progresses, has a significant impact on an individual's quality of life. In the latter stages of the disease, individuals often rely heavily on the support of spouses and family to act as carers and this can in turn compromise the health of the carer. Disease management is difficult and hospitalisation for episodes of acute illness is common and increases as the disease progresses. A comprehensive disease management plan that is closely monitored by health care practitioners can have a positive impact on the quality of life of the individual and their carers, and help minimise the need for hospital stays. The purpose of this profile is to provide an overview of the health needs of the Central Adelaide and Hills Medicare Local (CAHML) population with Chronic Obstructive Pulmonary Disease (COPD). By understanding the prevalence of COPD across the region, the risk factors and the characteristics of the populations at risk of developing COPD, regional health care providers and funders will be in a better position to determine how to most effectively and efficiently meet the health needs of the local population and reduce potentially preventable hospital admissions. This profile is designed to assist regional health care agencies plan the delivery of health care services. It quantifies what the need is in the community; the areas with the highest burden of disease; the social and economic circumstances of the at risk population; the strategies required to reduce this risk; and the ways in which disease progression and functional decline can be minimised. Central Adelaide and Hills Medicare Local - Chronic Obstructive Pulmonary Disease Central Adelaide and Hills Medicare Local - Chronic Obstructive Pulmonary Disease

4 Determinants and Risk Factors for COPD There are a number of underlying determinants and risk factors for COPD including genetic predisposition, ageing, early childhood health and development, and past history of respiratory illnesses. While these are important the impact of these risk factors is not felt at a population level in South Australia. In contrast, large numbers of people develop COPD through environmental exposures to air pollutants and noxious gases, in particular exposure to tobacco smoke. First hand smoking and regular exposure to second hand smoke can both lead to the development of COPD through the inhalation of particulates. The prevalence of smoking within a community is an important predictor for the incidence of COPD within that community. Indeed, there is a well established and strong direct causal relationship between smoking and the development of COPD. The following statistics demonstrate this relationship: Other environmental exposures, such as outdoor air quality tend not to pose the same level of risk in Australia, as most cities including Adelaide have relatively good air quality. There are a small number of specific locations within the Adelaide metropolitan area, where air pollution may be of concern, due to the level of emissions from local industries. Other documented risk factors that predispose individuals to COPD include disadvantage and poverty, poor housing conditions, low birth weight, and multiple lung infections during infancy and childhood. Even after adjusting for a history of smoking, people from low socio-economic status backgrounds have a higher rate of COPD, thus strengthening the suggestion that factors such as poor living conditions, exposure to other environmental pollutants and/or increased infections are likely to be contributing factors to the development of COPD. Determinants and Risk Factors for COPD: Genetic disposition Socio-economic status Age Gender Exposure to particles Tobacco smoke Occupational dusts Indoor air pollution from heating and cooking in poorly vented dwellings Outdoor air pollution First hand smoking and regular exposure to second hand smoke can both lead to the development of COPD through the inhalation of particles. Nearly 0% of deaths from COPD are attributable to smoking with the majority of COPD sufferers having a long history of tobacco use; [] Smokers risk of COPD increases with each cigarette smoked with almost, all smokers of 20 cigarettes per day show some degree of emphysema; [] Research has estimated that 0% of everyday smokers will go on to develop COPD. [] [0] Occupational exposures to dust is of serious concern for some workers, particularly those involved in coal mining or livestock farming. The combination of smoking and occupational exposure greatly increases the chance of developing COPD. While the CAHML community is unlikely to have high occupational exposures as a result of farming, it is possible with the increase of the Fly In Fly Out workforce within the mining sector that the prevalence of Adelaide residents being exposed to occupational dust is increasing. As the Fly In Fly Out workforce is expected to significantly expand, it is possible this workforce could pose an additional burden for regional health services in future years. It is therefore important to be aware of the changing workforce patterns within the region. Lung Growth and Development Oxidative stress Respiratory infections Previous tuberculosis Nutrition Comorbidities Central Adelaide and Hills Medicare Local - Chronic Obstructive Pulmonary Disease Central Adelaide and Hills Medicare Local - Chronic Obstructive Pulmonary Disease 7

5 COPD Determinants across the Region This section maps the distribution of disadvantage, prevalence, 'at risk' populations and risk factors associated with COPD across the CAHML region. As described previously, the principle risk factor for COPD is smoking, with the amount and length of time smoking increasing the risk. In order to understand the impact of COPD within the CAHML population, it is necessary to consider the socio-economic status, proportion of residents identifying as Aboriginal and Torres Strait Islander and most importantly the number of smokers. Socio-Economic Index for Areas (SEIFA) The ABS Index of Relative Socio-Economic Disadvantage is a useful summary indicator of disadvantage across regions. This summary measure provides an overview of many of the indicators of social inequality. Index of Relative Socio-Economic Disadvantage (IRSD) includes all variables collected in the Population Census that either reflect or measure disadvantage. These include low income, low educational attainment, high unemployment, jobs in relatively unskilled occupations and variables that reflect disadvantage, rather than measure specific aspects of disadvantage. [] The SEIFA map for the Central Adelaide and Hills region shows the least disadvantaged areas are situated in the eastern and hills part of the region, with the most disadvantaged areas in the west, excluding the suburbs of Grange and Henley Beach. This pattern of disadvantage is repeated in many of the other measures throughout this profile. Figure : Socio-Economic Index for Areas (SEIFA) Legend SEIFA Disadvantage SA SLA Region 2 Index: Australia = 000 Western Adelaide Central and Eastern Adelaide Adelaide Hills Statistical SLA Numbers Port Adel. Enfield (C) - Coast Charles Sturt (C) - Coastal Port Adel. Enfield (C) - Port Charles Sturt (C) - Inner West West Torrens (C) - West Port Adel. Enfield (C) - Park Charles Sturt (C) - North East Charles Sturt (C) - Inner East West Torrens (C) - East Prospect (C) Adelaide (C) Unley (C) - West Unley (C) - East Walkerville (M) Norw. P'ham St Ptrs (C) - West Burnside (C) - South West Norw. P'ham St Ptrs (C) - East Burnside (C) - North East Campbelltown (C) - West Campbelltown (C) - East Adelaide Hills (DC) - Ranges Adelaide Hills (DC) - Central Adelaide Hills (DC) - North Adelaide Hills (DC) - Bal Mount Barker (DC) - Central Mount Barker (DC) - Bal Central Adelaide and Hills Medicare Local - Chronic Obstructive Pulmonary Disease Central Adelaide and Hills Medicare Local - Chronic Obstructive Pulmonary Disease

6 COPD Risk Factors across the Region Current Smokers Figure 2: Current Smokers Figure : Indigenous Status Aboriginal Population as Proportion of Total Population 20 Census There is a strong relationship between smoking rates and levels of disadvantage. In South Australia the smoking prevalence rate across the adult population is 7.%. This map documents the level of smoking across the Central Adelaide and Hills region which not surprisingly closely mirrors the previous map of socio-economic disadvantage. Highest smoking rates between % and % of the population, are located in the west of the region and along the Le Fevre Peninsula. There are markedly more smokers in these suburbs, when compared with the South Australian rate of 7.%. [] Legend Rate as % Smoking is more prevalent among communities that are experiencing social disadvantages such as low income, high unemployment, poor housing and lower levels of educational attainment. A specific focus on smoking prevalence reduction and prevention strategies is required to make the most Legend Current Smokers SA SLA Region Rate per 00 people Aboriginal and Torres Strait Islander Population There is evidence that Aboriginal and Torres Strait Islander people start smoking at an earlier age, smoke for longer, and make fewer quitting attempts than the broader Australian population. 2 There is limited data available on the smoking rates for Indigenous South Australians and what data is available tends to be reported at the whole of State level. impact on smoking rates in these groups. [] The Aboriginal and Torres Straight Islander population within the CAHML region is clustered around Port Adelaide and its surrounding suburbs. Relatively low numbers of Aboriginal people living within CAMHL reside outside this cluster of suburbs. Mount Barker appears to be the only exception with slightly more Aboriginal people living there compared to other parts of the Hills. [] 0 Central Adelaide and Hills Medicare Local - Chronic Obstructive Pulmonary Disease Central Adelaide and Hills Medicare Local - Chronic Obstructive Pulmonary Disease

7 COPD Prevalence across the Region Hospital Admission Rates COPD Prevalence In the annual prevalence of COPD in CAHML was estimated at 2,22 cases, or 2.% of the population. Comparable with the Australian prevalence of 2.% and the South Australian prevalence of 2.%. Other studies have shown prevalence as high as.7% -.% in metropolitan Adelaide, 7.% to % in people aged 0 or over, or 2.2% in people aged 7 and over. [] Under-diagnosis is a recognised issue with determining COPD prevalence. It has been estimated that for every person diagnosed with COPD, there are approximately four people with undiagnosed COPD. [] 2 Figure : COPD Prevalence As COPD progresses and lung function deteriorates individuals are more likely to make episodic visits to hospital to control and manage exacerbations and complications. CBD. As can be seen, COPD is among the most common causes for admission at both centres, ranking third highest at the RAH and highest at the TQEH. This is likely to be a reflection of the higher prevalence of COPD in Adelaide s western suburbs. Further to this, The table below shows the avoidable hospital admissions in two of the major tertiary centres in the CAHML region, The Queen Elizabeth Hospital (TQEH) located in the western suburbs of Adelaide, and the Royal Adelaide Hospital (RAH), located in the Adelaide admissions to hospital due to COPD tend to be of longer duration than for other chronic conditions. For example, in there were 2,0 hospitalisations in Australia attributed to COPD with an average length of stay of 7 days. [2] Table : Avoidable Hospital Admissions date Condition TQEH RAH Disadvantaged groups face particular challenges as health concerns may be just one dimension of a series of interconnected problems, that people living in these circumstances face. Efforts to address health inequalities associated with chronic disease, and in particular COPD, need to be designed to take into account local circumstances and context, as well as social and environmental barriers to change. This may often require closer linkages between health sector initiatives and other programs and services that affect people s lives. Legend SA SLA Region 2 2 Angina 7 2 Appendicitis Asthma Chronic Obstructive Pulmonary Disease 02 2 Cellulitis 00 Congestive Cardiac Failure 7 Convulsions/Epilepsy 20 7 Dehydration/Gastroenteritis 0 Dental 2 Diabetes Complications Rate per 00 people 2 Ear Nose Throat 0 Gangrene 0 Hypertension Influenza/Pneumonia 77 Iron Deficiency Anaemia 0 Nutrition 0 Other vaccine Pelvic Inflammatory Disease 7 Perforated/Bleeding Ulcer 7 Pyelonephritis 7 Rheumatic Heart Disease 7 07 PPA Total Episodes,,2 PPA Total Patients,, 2 Central Adelaide and Hills Medicare Local - Chronic Obstructive Pulmonary Disease Central Adelaide and Hills Medicare Local - Chronic Obstructive Pulmonary Disease

8 Hospital Admission Rates The map below details the number of individuals who were admitted to hospital for COPD across CAHML, and where the admissions were considered to be preventable; potential preventable hospital admissions (PPA s). These are hospital stays which might be avoided if appropriate, necessary and timely health care was provided in the community. Similar to COPD prevalence, the pattern continues with the north west, Campbelltown and Mount Barker regions having the greatest numbers of PPA's. Key Message "At Risk" groups require access to integrated services. A recent report from the Australian Institute of Health and Welfare (AIHW, 20), investigating how hospitalisation rates vary by geographic distribution across Australia found that SES, remoteness and the proportion of the population that identifies as Indigenous were strongly associated with hospitalisation rates for COPD by area. Further modelling found that COPD hospitalisation rates were higher in statistical sub divisions with a higher proportion of Aboriginal and Torres Strait Islanders by a factor of.02 for every percentage increase in the proportion of Indigenous Australians in the area. COPD hospitalisation rates were larger by a factor of. in statistical sub divisions in the lowest SES quintile compared with statistical sub divisions in the highest SES quintile. These recent findings further confirm the importance of working with the local Aboriginal and Torres Strait Islander Communities and low SES populations living in CAHML. [] COPD is a major cause of death in Australia, responsible for % of all deaths in recent years. [] Figure shows the standardised premature death rate from COPD in the CAHML region aged - years. For the areas with sufficient numbers to be mapped, the pattern closely aligns with earlier maps, with the west of the region recording the highest rate. [] This monograph clearly highlights the concentrated areas of COPD prevalence across the region, and identifies the population groups within the region at greatest risk of developing the disease and then subsequently dying from the condition. The population need is highest in the west of the region of CAHML with other pockets of need in the Mount Barker and Campbelltown areas. Legend PPAs for COPD 200/0 to 200/07 Figure : People having COPD PPAs to (Average) Figure : Premature Mortality Standardised Death Rate of COPD -7 years CAHML Legend Deaths from COPD 200 to 200 to (SDR) SA Health: COPD PPA separations from SA public hospitals experienced by residents of CAHML PHIDU, Social Health Atlas of Australia. February 20 Central Adelaide and Hills Medicare Local - Chronic Obstructive Pulmonary Disease Central Adelaide and Hills Medicare Local - Chronic Obstructive Pulmonary Disease

9 Chronic Disease Management Continuum Primary Prevention As discussed previously smoking is well established as the main causal risk factor for COPD. Smoking prevention and cessation are the most effective strategies to prevent the onset of the disease, to reduce further loss of lung function and to slow disease progression. Thus strategies focussing on primary prevention and secondary prevention, following early diagnosis, should be considered a priority in order to reduce the burden of disease. However, despite the implementation of prevention strategies, there will always be individuals who go on to develop COPD. The health system can support these individuals through timely and effective access to strategies and services that help to manage and control the disease s progression, working across the continuum of care. There are opportunities to promote good health and prevent both the development and progression of disease at all stages across the continuum. The model outlined in Figure 7 demonstrates the need for a whole system response to chronic disease prevention and management, with different parts of the health system responsible for different parts of the continuum. It is important to ensure that clear pathways and links are established and maintained between and across the system, and between the levels of the care. Key Message Chronic obstructive pulmonary disease is a disease of inequality. Key Message Action is required across the Chronic Disease Prevention Control Continuum. Well Population Primary Prevention Promotion of healthy behaviours and environments across the life course Universal and targeted approaches Public health Primary health care Other sectors Health Promotion Prevent Movement The "At Risk" Group Figure 7: Comprehensive Model of Chronic Disease Prevention and Control At Risk Secondary Prevention / Early Detection Screening Case finding Periodic health examinations Early intervention Control risk factors lifestyle and medication Primary health care Public health Established Disease Treatment and Acute Care Complications management Specialist services Hospital care Primary health care Health Promotion Health Promotion Health Promotion Prevent Progression To Established Disease and Hospitalisation Controlled Chronic Disease Disease Management and Tertiary Prevention Continuing Care Maintenance Rehabilitation Self management Primary health care Community care Prevent/Delay Progression To Complications & Prevent Readmissions State and Territory governments have the responsibility for population primary prevention activities and the South Australian government has documented its commitment to the primary prevention of smoking, in the Tobacco Control Strategy The Strategy details a comprehensive series of evidenced based interventions designed to reduce the incidence and prevalence of smoking, with a particular focus on young people and Aboriginal and Torres Strait Islanders. The strategy outlines action at the population level, but primary prevention action is also required at the individual level. Optimising prevention strategies and messages with individuals every time they interact with the health care system, plays an important complementary role to population level interventions. This is a key role for the primary care sector and in particular general practice. Central Adelaide and Hills Medicare Local - Chronic Obstructive Pulmonary Disease Central Adelaide and Hills Medicare Local - Chronic Obstructive Pulmonary Disease 7

10 Secondary Prevention and Early Diagnosis Tertiary Prevention - Management and Control During its earliest stages, COPD can only this study have particular relevance for the Central and be identified through the use of spirometry. Adelaide Hill s population as the study subjects were Early clinical signs, such as wheezing and drawn from this catchment. [] breathlessness, are poor indicators of disease and as a result individuals and health care The figure below (Figure ) compares the national professionals alike often fail to recognise disease benchmark or expected rate of COPD within the development. As a result, COPD is not usually general practice patient community with the COPD diagnosed until it is moderately advanced and prevalence rate from a sample of general practices begins to impair quality of life. [2] in the Adelaide Western area of CAHML. In comparison with the national benchmark, the rate of COPD cases The use of spirometric assessment within general in these practices is low. This could be because the practice is an important strategy to accurately identify actual numbers of people with COPD in the CAHML individuals at risk and diagnose the early stages of Adelaide western region is lower than the national COPD. Further to this, thorough and individually tailored benchmark rate. Alternatively there might be a sizeable management plans should be instituted to reduce proportion of people living within the region who have risk factors, control and slow the progression of the undiagnosed COPD. Given the socio-economic profile disease. [] Given this evidence, it is not surprising that of the region and the high smoking prevalence, it is COPD is thought to be under-diagnosed. The North suggested that COPD is under diagnosed across the West Adelaide Study found that significant numbers whole CAHML region. If this is the case it is important of individuals with mild and moderate COPD, and to consider strategies that increase early diagnosis such some with severe COPD, had not been diagnosed as increasing the rate of screening and diagnosis and and that this phenomenon seemed to be related to risk factor reduction, in particular smoking cessation, smoking status, with ex-smokers under diagnosed as evidence suggests that smoking cessation at early when compared with current smokers. The findings of stages of COPD is more effective than in the later stages. Figure : Prevalence of COPD in GP practices in the Adelaide western area Age Specific Patient Population % 0 Based on aggregated data from practices in the Western Region (200) COPD Profile Age Group National COPD Benchmark (age specific rate)* The goals of effective COPD management are to prevent disease progression; relieve symptoms; improve exercise tolerance; improve health status; prevent and treat complications; prevent and treat exacerbations and reduce mortality. According to the World Health Organization (WHO) COPD management should include four elements: assess and monitor the disease; reduce risks factors, such as smoking and other environmental exposures; manage stable COPD, characterised by a step wise increase in treatment depending on the severity of the disease; and manage exacerbations. People with COPD, particularly current or past tobacco smokers, often suffer from other related diseases, and recurrent infections or allergies, which can complicate both the symptoms and treatment of the disease. While medications do not modify the long term decline in lung function, they do play an important role in minimising symptoms and thereby improving the quality of life of individuals with COPD. [2] In addition to pharmacotherapy, individuals with COPD benefit from exercise training programs, which can improve their exercise tolerance, reduce symptoms and improve quality of life. It is recommended by WHO and the Australian COPD-X guidelines that exercise programs are included as part of any COPD management plan. People with COPD, particularly current or past tobacco smokers, often suffer from other related diseases, and recurrent infections or allergies. Key Message Clearly define and document COPD management goals. Improving the health literacy of individuals with COPD can assist them to manage their disease. Likewise increasing the health literacy of some health care providers to better understand the context in which they are treating the disease, their role in the system and the challenges people face trying to navigate the health care system can also improve chronic disease outcomes. Pulmonary rehabilitation is a COPD specific rehabilitation strategy that incorporates exercise, education and breathing techniques to improve quality of life and patient self management. For suitable individuals it combines exercise training and health literacy, and increases self confidence resulting in improved patient health and wellbeing. The effectiveness of pulmonary rehabilitation has been well established; the challenge is that access to these programs is very limited and often associated with significant out of pocket expenses if accessed outside the public sector. [] Key Message Increased exercise and education benefits people with existing COPD. Central Adelaide and Hills Medicare Local - Chronic Obstructive Pulmonary Disease Central Adelaide and Hills Medicare Local - Chronic Obstructive Pulmonary Disease

11 Conclusions and Suggested Directions Strategic Directions Primary Prevention Secondary Prevention - Case Finding It is apparent from the evidence and data presented in this monograph that the burden of COPD falls unevenly across CAHML, with the population living in the west carrying the highest burden. Mount Barker and Campbelltown also appear to have increased burden compared with the rest of the region but this appears less than the west. The evidence also indicates that within the western region, people from low SES backgrounds and those that identify as Indigenous, are more likely to engage in risk taking behaviours such as smoking. This predisposes these individuals to develop COPD. Those diagnosed with COPD have higher hospital admission rates and higher death rates. The following directions are designed to support strategy development to reduce COPD, deliver better health outcomes for individuals living with COPD, reduce the hospital admission rates and ultimately reduce health system costs and improve population health outcomes. It is suggested that a tailored approach be taken to addressing COPD within the CAHML region, which includes targeting locations and particular population groups working across the chronic disease continuum of care. Population Groups Identified People living in the north-west of the CAHML region Aboriginal and Torres Strait Islander people Low socio-economic status groups Individuals that currently smoke Previous smokers with an extended smoking history (20+ years) Preventing the uptake of smoking, or assisting individuals to quit smoking, are the most useful strategies in reducing the burden of COPD. Preventing individuals taking up smoking, or assisting individuals to quit smoking, are the most useful strategies in reducing the burden of COPD. While rates of smoking have fallen across all population groups, they are still high amongst people from low socio-economic backgrounds and Aboriginal and Torres Strait Islander people. [] Recommendations. Adopt a place based approach that complements the South Australian government s population level primary prevention Tobacco Control Strategy with a focus on high risk groups living in the western region of the CAHML. This could include targeted strategies to increase smoking cessation and prevent up take amongst Aboriginal and Torres Strait Islander people and low SES groups living in the west of CAHML. 2. Increase health literacy about COPD in the whole community, with a focus on high risk groups and in key settings.. Increase individual primary prevention action across CAHML through consistent use of opportunistic interactions between GPs and individuals presenting with COPD risk factors. Brief interventions by GPs with their smoking patients have demonstrated an increase in smoking cessation. This strategy should be extended to include other regional health care providers. Early diagnosis and treatment can improve individual health outcomes and reduce the costs associated with preventable hospital admissions. Increasing access for at risk groups to be screened and diagnosed early is an important component of a comprehensive strategy to reduce the burden of COPD within a given community.. Increase COPD case finding within general practice across the CAHML region. Investigate what the barriers are, if any to using spirometry within general practice. (NB there is an MBS item number for Spirometry- MBS 0 $7.0). 2. For younger populations, or individuals less likely to regularly visit a GP, consider trialling a workplace screening and education program. The screening program could focus on industries within the western sub-region, Campbelltown and Mount Barker regions.. Promote the use of COPD management plans for all diagnosed individuals within General Practice, across the region. The plans should include strategies that support and identify referral pathways to assist individuals stop smoking, increase exercise, improve health literacy and manage their condition. 20 Central Adelaide and Hills Medicare Local - Chronic Obstructive Pulmonary Disease Central Adelaide and Hills Medicare Local - Chronic Obstructive Pulmonary Disease

12 Conclusions and Suggested Directions Tertiary Prevention - Treatment and Management System Enablers References. Australian Institute of Health and Welfare 20. Geographic distribution of asthma and chronic obstructive Tertiary prevention aims to slow the disease progression, reduce hospital visits and maintain the quality of life of individuals, their carers and families. Health care providers need to work in partnership with individuals to advise and support them, wherever possible empowering them to control their condition. System enablers are an important part of an effective population based primary health care strategy and should include strategies that increase coordination and partnerships across and within the region; utilise and strengthen the evidence base through research; evaluation and monitoring; and build the capacity of the health care workforce.. David K McKenzie, Michael Abramson, Alan J Crockett, Eli Dabscheck, Nicholas Glasgow, Sue Jenkins, Christine McDonald, Richard Wood-Baker, Ian Young, Peter A Frith on behalf of The Lung Foundation Australian. The COPD-X Plan: Australia and New Zealand Guidelines for the Management of Chronic Obstructive Pulmonary Disease V2.0, 20 pulmonary disease hospitalisations in Austrlaia to Cat. no. ACM 2. Canberra: AIHW 0. Rafael Laniado-Lorbin. Smoking and Chronic Obstructive Pulmonary Disease (COPD). Parallel epidemics of the st century. International Journal Environmental Research and Public Health, Encourage and facilitate the use of COPD management plans with patients amongst all general practices across the region based on the COPD-X guidelines. In addition, the plans should include strategies that support and identify referral pathways to assist individuals stop smoking, increase exercise, improve health literacy and manage their condition. 2. Develop strategies to assist general practice to identify and refer appropriate individuals to pulmonary rehabilitation and support groups.. Liaise with the Queen Elizabeth Hospital and Royal Adelaide Hospital Respiratory Units to assist with optimising use of their resources for COPD management.. Increase understanding of the barriers to accessing local services by at risk groups within the CAHML region and implement strategies to reduce these barriers. Work with regional health care providers to build a shared understanding of barriers and solutions. 2. Improve individual's interaction with the regional health system through improved patient pathways and integration and coordination of services.. Increase understanding of the Social Determinants of Health, and health inequities experienced by individuals from high risk populations, and work to deliver improved health and treatment outcomes for these individuals. 2. World Health Organization. WHO strategy for the prevention and control of chronic respiratory. WHO Australian Institute of Health and Welfare (AIHW). Chronic diseases and associated risk factors in Australia, 200. Canberra: AIHW; State of our Health: Health Status and Health Determinants of South Australians (working draft). May 20.. Drug and Alcohol Services South Australia. Tobacco Control Strategy 20-. Drug and Alcohol Services South Australia. May 20.. David Wilson, Robert Adams, Sarah Appleton et al.. Australian Institute of Health and Welfare 20. AIHW Access- What about Chronic Obstructive Pulmonary Disease (COPD) Cat. no. HWI Canberra AIHW. 2. Brett G Toelle, Wei Xuan, Michael J Abramson et al. Respiratory symptoms and illness in older Australians: the Burden of Obstructive lung Disease (BOLD) Study. MJA (). February 20 Difficulties identify and targeting COPD and population attributable risk of smoking for COPD. A Population Study. CHEST 2. () October National Public Health Partnership. Preventing chronic disease: A strategic framework. Background paper. NPHP. October Public Health Information Development Unit. Social Health Atlas of Australia: Medicare Locals, 20. Public Health Information Development Unit. University of Adelaide. We acknowledge Health First Network for collating this population health information for the region. We also acknowledge the Lung Foundation for providing selected photographic images for this publication. Central Adelaide and Hills Medicare Local - Chronic Obstructive Pulmonary Disease Central Adelaide and Hills Medicare Local - Chronic Obstructive Pulmonary Disease 2

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