Arizona Comprehensive Lung Disease Control Plan “ The Arizona Department of Health Services initiated the development of this plan with the intent to set priorities by formulating objectives and suggesting strategies to address chronic obstructive pulmonary disease as a serious public health issue in Arizona. ” Letter From Our Director Dear Arizona Residents: Chronic Obstructive Lung Disease (COPD) is a major health problem in Arizona and is the third leading cause of death in our state. In the United States, COPD is ranked the fourth leading cause of morbidity and mortality; the incidence of the disease is on the rise. The Arizona Department of Health Services has developed the Arizona Comprehensive Lung Disease Control Plan. This plan sets the priorities, objectives, and strategies to reduce deaths attributable to COPD and to aid in reducing the adult population in Arizona who become disabled due to chronic lung disease. In addition, the plan promotes improvements in the system of care for individuals diagnosed with COPD, as well as promoting the prevention and early detection of lung disease. The risk factors for COPD include genetic, physical wellness, behavioral, and environmental components: the greater being behavioral and environmental. It is estimated that 80% to 90% of COPD cases in the United States are attributable to tobacco smoking. This presents a tremendous challenge to the public health community in the areas of prevention and early detection given that smoking abstinence can prevent the occurrence of COPD, and smoking cessation has a powerful influence on determining the outcome for those who suffer from this disease. The plan is designed to assist stakeholders, policymakers, health care professionals, educators, and public health workers in developing and coordinating approaches to address COPD among their constituents. The plan is an important step in raising awareness of the serious public health problem of COPD, and it provides a framework for action to reduce the impact of lung disease in Arizona. Sincerely, Susan Gerard Director Arizona Comprehensive Lung Disease Control Plan 1 Ta b l e o f C o n t e n t s Ta b l e o f C o n t e n t s I. Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 II. Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 III. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 Definition of COPD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 Burden of COPD in Arizona . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 Burden of COPD in the United States . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 Risk Factors for COPD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16 Diagnosis and Staging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22 Treatment and Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 Exacerbations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32 IV. Objectives Sections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35 Epidemiology and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35 Treatment and Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37 Patient Education and Quality of Life Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42 Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45 Disparity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46 Collaborative Efforts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48 Advocacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48 Public Awareness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49 Future Directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50 V. References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53 Arizona Comprehensive Lung Disease Control Plan 3 Acknowledgements Acknowledgements TRUST Commission Special Thanks The Arizona Department of Health Services Janet Bourbouse, M.A. would like to thank the Advisory Council of the Arizona Department of Health Services Tobacco Revenue Use, Spending and Tracking (TRUST) Commission for supporting the development of the Arizona Comprehensive Lung Disease Control Plan. Nancy Cohrs, R.R.T., R.C.P. American Lung Association of Arizona Dilia Loe, M.T.S. Arizona Department of Health Services Authors William Pfeifer, President/CEO Meryl S. Salit, R.R.T., R.C.P., M.B.A. American Lung Association of Arizona/New Arizona Department of Health Services Mexico Rhonda Kay Follman, M.S. Patricia Tarango, M.S. American Lung Association of Arizona Arizona Department of Health Services Margaret Tate, M.S., R.D. Arizona Department of Health Services Arizona Comprehensive Lung Disease Control Plan 5 Executive Summary Executive Summary Chronic Obstructive Pulmonary Disease (COPD), also known as Chronic Obstructive Lung Disease or Chronic Lower Respiratory Disease, is a major public health problem. It is projected to rank fifth in 2020 as a world-wide burden of disease underlying cause of death, or may not be cited at according to the World Bank/World all, rather than being the attributed cause of death.6 Health Organization.1 It is currently COPD is not characterized by the drama that the fourth leading cause of morbidity and mortality in the United States,2 and in 2002, COPD was the 3 third leading cause of death in Arizona. COPD is also the only major disease that is rising in prevalence and mortality while all other major causes of death are declining.4 Although COPD is such a significant cause of mortality and morbidity worldwide, it has failed to receive commensurate attention from the healthcare community and government officials. This can be attributed to various factors. There is incomplete information about the causes and prevalence of COPD. Prevalence and mortality data greatly underestimate the total burden of COPD because the disease is usually not diagnosed until it is clinically apparent and moderately advanced.5 Mortality data also underestimate COPD as a cause of death surrounds sudden and life-threatening illness such as heart attack and stroke, which has brought the 7 combined efforts of the public, governmental agencies, and the medical community to devise effective strategies for prevention and early treatment for these chronic diseases. By contrast, COPD lacks compelling symptoms or may be asymptomatic during years of progressive loss of lung function on the pathway to disabling dyspnea and premature mortality from acute and chronic respiratory failure.7 One of the most frightening aspects of this disease is the fact that many afflicted with COPD do not realize they have it until they have lost significant lung function, at which time mundane activities such as walking short distances can become difficult. Often the symptoms of COPD are attributed to a common cold, allergies, because the disease is more likely to be cited as an Arizona Comprehensive Lung Disease Control Plan lack of exercise, or aging and are therefore unrecog- “disease” (e.g. normal subjects with outlier labora- nized by patients or underdiagnosed by physicians. tory values).9 According to the American Lung Association, These factors have resulted in surprisingly little smoking causes 80 to 90% of COPD cases; and being known about the disease beyond its clinical smokers are 10 times more likely than nonsmokers nature. Studies of the disease burden on COPD to die of the disease.8 The association of the disease patients are scarce, and the social and healthcare with smoking has also attributed to its lack of costs of the disease have not been well quantified. importance, since until recently it was seen as a There are limited data about COPD symptoms and self-inflicted consequence of a bad habit, rather severity, disability or activity limitations, lifestyle than the tragic outcome of an addiction. impact, social and psychosocial consequences, There is also confusion around the term COPD among patients and healthcare professionals, which healthcare utilization and current patterns of treatment.10 The Arizona Department of Health Services complicates epidemiologic studies of COPD. 8 Patients may be diagnosed with smoker’s lung, initiated the development of this plan with the intent emphysema, bronchitis, chronic bronchitis, chronic to set priorities by formulating objectives and obstructive bronchitis or obstructive lung disease suggesting strategies to address chronic obstructive and not identify with the term COPD. pulmonary disease as a serious public health issue Self-report of physician diagnosis is a poor in Arizona. This plan begins with a detailed measure of COPD prevalence, as in reports of description of chronic obstructive lung disease impaired lung function from the National Health followed by a discussion of proposed objectives and and Nutrition Examination Survey (NHANES) III strategies. The overriding goals of this plan are which carefully defined “obstructive” but included those stated in the Healthy People 2010: Objectives in the analysis those in whom the impairments may for Improving Health. It is important that a not have been “chronic” (e.g. viral infection), comprehensive approach be taken in working “pulmonary” (e.g. congestive heart failure), or toward these ambitious goals in Arizona, involving the collaboration of community stakeholders. TA B L E 1 Overriding Goals Reduce the proportion of adults in Arizona whose activity is limited due to chronic lung disease. Reduce deaths from COPD among Arizona adults. Executive Summary TA B L E 2 P l a n O b j e c t i v e s b y To p i c Epidemiology and Research 1. Establish a surveillance system to accurately track the mortality and morbidity of COPD in Arizona, and also measure the impact on the economy of the state. 2. Support research into COPD etiology and clinical management, as well as healthcare policies and outcomes particularly as the activities relate to state issues. Treatment and Management 3. Improve early detection and diagnosis of COPD. 4. Promote better care for patients with COPD in Arizona according to established guidelines. 5. Educate healthcare providers to manage patients with COPD to increase longevity and quality of life and reduce exacerbations of the disease. 6. Establish physician-patient partnerships through education and management. 7. Improve access to pulmonary rehabilitation programs for Arizonans with COPD in order to prevent and forestall premature morbidity and mortality. Patient Education and Quality of Life Issues 8. Improve self-management knowledge and behavior in people with COPD, their families and other caregivers. 9. Provide social support for patients, families, and caregivers impacted by COPD. Prevention 10. Promote healthy living practices, which provide the most effective method of preventing COPD (tobacco abstinence, periodic health checks, avoidance of unhealthy work environments). 11. Reduce exposure to environmental and occupational risk factors to prevent the onset and progression of COPD. Disparity 12. Identify and eliminate disparities in COPD prevention, diagnosis, and management throughout the state. Collaborative Efforts 13. Foster communication, collaboration and networking opportunities among patients, caregivers, healthcare professionals, public health officials and other stakeholders. Advocacy 14. Advocate and support policies to reduce the prevalence of tobacco use and secondhand smoke exposure among Arizonans. Public Awareness 15. Increase awareness of the medical community, public health officials and the general public that COPD is a serious public health problem in Arizona. Arizona Comprehensive Lung Disease Control Plan 9 Introduction Introduction Definition: Chronic obstructive pulmonary disease (COPD) is defined as a disease state characterized by the presence of airflow obstruction due to chronic bronchitis or emphysema. The airflow Chronic bronchitis is characterized by chronic cough and sputum production, intermittent wheezing with variable degrees of shortness of breath on exertion, recurring and continuing for months. obstruction is generally progressive, accompanied Chronic bronchitis results from inflammation and by airway hyperreactivity, and may be partially swelling of the cells, which line the bronchus. This reversible. In the past asthma was also classified as inflammation causes the production of excessive COPD, however it has been determined that the mucus. Both the swelling and excess mucus reversibility of asthma and the characteristic contribute to the narrowing of the bronchi, making inflammation with participation of complex cellular air exchange more difficult and increasing the risk and chemical mediators distinguishes it from these of lung infections. conditions and it has been separated. However, the obstruction in many patients with COPD may include a significant reversible component and some patients with asthma may go on to develop irreversible airflow obstruction indistinguishable from COPD. In chronic bronchitis, the mucous glands in the lungs become larger. The airways become inflamed, and the bronchial walls thicken. These changes and the loss of supporting alveolar (air space) attachments limit airflow by allowing the airway walls to 11 deform and narrow the airway lumen (the inside of Chronic bronchitis is defined as the presence the airway tube). of chronic productive cough for three months in Emphysema is defined as abnormal permanent each of two successive years in a patient for whom other causes of chronic cough have been excluded.12 enlargement of the airspaces distal to the terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosis. Destruction is Arizona Comprehensive Lung Disease Control Plan 11 defined as lack of uniformity in the pattern of respi- reveals 13,638 hospitalizations for COPD, which is ratory airspace enlargement; the orderly appearance a rate of 249.2 per 100,000 population. Estimates of the acinus and its components is disturbed and of prevalence derived from the National Health may be lost.13 It is an abnormal, permanent enlarge- Interview Survey (NHIS) conducted by the National ment of the air spaces (alveoli) located at the end of Center for Health Statistics, Centers for Disease the breathing passages of the lungs (terminal bron- Control and Prevention in 2001 and based on chioles), accompanied by the damage to the walls Department of Economic Security population between the air spaces in the lungs. This leaves less estimates for 2004 indicate that the total number of surface area for the normal exchange of oxygen and Arizonans with COPD is 290,124.14 carbon dioxide. Emphysema reduces the normal elasticity of the lung that helps to hold the airways open. As a result, the lungs lose their elasticity and exhalation becomes more and more difficult. Air remains trapped in the overinflated lungs. Those with emphysema experience progressive shortness of 12 breath on exertion, variable degrees of coughing and wheezing, and irreversible airflow obstruction. Figure 1 and Figure 2 from the Arizona Health Status and Vital Statistics Report of 2003 illustrates the burden of COPD (referred to as chronic lower respiratory diseases) in Arizona:15 Figure 2 illustrates the burden as distributed among racial and ethnic groups in Arizona.16 The number of deaths in Arizona from chronic lower respiratory diseases by county is illustrated in Figure 3.17 There are significant problems in the accuracy Burden of COPD in Arizona According to the Arizona Department of Health Services Public Health Prevention Services, “Arizona Chronic Disease Surveillance Indicators Report,” September 2004, chronic lower respiratory disease (synonymous with chronic obstructive pulmonary disease) was the third leading cause of death in Arizona for 2002, and accounted for 6% of all deaths. Hospital discharge data for that year of this data. Reporting on cause of death often will not indicate COPD as a cause of death, since it may be seen only as a contributing factor to death due to cardiopulmonary failure, pneumonia, or influenza, or it may not be listed at all. The same is true with hospitalization data, which in addition does not include emergency department or urgent care visits, nor does it include those Arizona residents receiving care in any Federal facility. The NHIS data is dependent on the patient self-identifying that they have been diagnosed with either chronic bronchitis or emphysema. The question regarding emphysema asks whether the individual had “ever” been told by a doctor or other Introduction FIGURE 1 Tw e l v e L e a d i n g C a u s e s o f D e a t h Among Arizona Residents in 2003 BASED ON THE NUMBER OF DEATHS: 1. Diseases of heart 10,649 2. Malignant neoplasms 9,451 3. Chronic lower respiratory diseases 2,522 4. Accidents (unintentional injuries) 2,466 5. Cerebrovascular disease 2,356 6. Alzheimer’s disease 1,691 7. Influenza and pneumonia 1,248 8. Diabetes mellitus 1,124 9. Intentional self-harm (suicide) 807 10. Chronic liver disease and cirrhosis 625 11. Nephritis, nephrotic syndrome and nephrosis 550 12. Assault (homicide) 480 0 2,500 5,000 7,500 10,000 12,500 13 BASED ON AGE-ADJUSTED* MORTALITY RATES: 1. Diseases of heart 197.1 2. Malignant neoplasms 169.4 3. Chronic lower respiratory diseases 45.4 4. Accidents (unintentional injuries) 44.8 5. Cerebrovascular disease 43.9 6. Alzheimer’s disease 32.5 7. Influenza and pneumonia 8. Diabetes mellitus 9. Intentional self-harm (suicide) 23.4 20.3 14.6 10. Chronic liver disease and cirrhosis 11.5 11. Nephritis, nephrotic syndrome and nephrosis 10.1 12. Assault (homicide) 0.0 8.3 50.0 100.0 150.0 200.0 250.0 * Number of deaths per 100,000 population age-adjusted to the 2000 U.S. standard. Note: the cause-of-death titles are according to the Tenth Revision of the International Classification of Diseases (ICD-10) Arizona Comprehensive Lung Disease Control Plan health professional that they had the condition. The chronic bronchitis question asks if they had been told by a doctor or health professional if they have had the condition in the past 12 months. As we see from the American Thoracic Society (ATS) definition of chronic bronchitis, it is diagnosed over two successive years, so a “yes” answer may represent Burden of COPD in the United States COPD is a major cause of morbidity and mortality in the United States. An estimated 11.2 million adults have ever reported a physician diagnosis of COPD. A recent survey found that 24 million U.S. adults have some evidence of impaired confusion with a viral bronchial illness. lung function, indicating under diagnosis of COPD. Unfortunately, since diagnosis of COPD usually The economic toll on the U.S. is quite heavy. takes place when it is well advanced due to late According to estimates made by the National Heart onset of symptoms, these self-reported numbers Lung and Blood Institute in 2004, the annual cost to tend to be significantly lower than actual incidence. Because of the limited data currently available the nation for COPD was $37.2 billion, including $20.9 billion in direct healthcare expenditures, $7.4 for social and economic impact of COPD in billion in indirect morbidity costs, and $8.9 billion Arizona, these indicators will be addressed on a in indirect mortality costs.18 In 2000, COPD was national level. responsible for 8 million physician office and hospital outpatient visits, and 726,000 hospitaliza- 14 tions in the U.S. FIGURE A g e - A d j u s t e d M o r t a l i t y R a t e s f o r C h ro n i c L o w e r R e s p i r a t o r y D i s e a s e s b y R a c e / E t h n i c G ro u p , A r i z o n a , 2 0 0 3 2 White (non Hispanic) 48.3 ALL ARIZONANS 45.4 Black 30.3 Hispanic 28.7 American Indian Asian 0.0 19.4 15.5 15.0 30.0 45.0 Number of deaths per 100,000 population age-adjusted to the 2000 U.S. standard 60.0 Introduction FIGURE 3 D e a t h s f ro m C h ro n i c L o w e r R e s p i r a t o r y D i s e a s e s By County of Residence, Arizona, 2003 Coconino Apache 53.3 32.8 Mohave 57.5 Navajo 36.6 Yavapai 42.9 La Paz Gila 15 Greenlee 68.6 Maricopa 43.8 Yuma 35.3 Pinal 37.5 31.5 Graham 51.7 47.8 Pima 47.0 Cochise 50.6 31.5-37.5 37.6-47.8 45.0 Santa Cruz 47.9-68.6 NUMBER OF DEATHS PER 100,000 POPULATION (age-adjusted to 2000 standard) ARIZONA RATE = 45.4 Arizona Comprehensive Lung Disease Control Plan The impact of COPD to the working population is underestimated, due to the assumption that it is a disease of the elderly. According to Centers for Disease Control data published in 2002, 70% of COPD patients were below the age of 65.19 The disability caused by COPD is significant and is documented in a survey released by the American Lung Association in 2001, “Confronting C.O.P.D. in America.” It revealed that 51% of COPD patients say their condition limits their ability to work, limits them in normal physical exertion (70%), household chores (56%), social activities (53%), sleeping (50%) and family activities (46%).20 Beyond the debilitation of the patient, the burden on the families of COPD patients is tremendous, particularly in the later stages of the disease, when mild exertion is difficult and the patient 16 ceases to be ambulatory. This leads to more lost wages, and numerous lifestyle accommodations required on the part of the caregivers. The burden of COPD in the United States appears to be generally increasing across many demographic groups. Data is limited since it is self-reported, and does not include the large number of undiagnosed cases of COPD, or hospitalizations where COPD is not listed as the admitting diagnosis. Risk Factors for COPD Tobacco Use The primary risk factor for COPD is tobacco smoking, which accounts for an estimated 80 to 90% of the deaths caused by COPD. Male smokers are nearly 12 times as likely to die from COPD and female smokers 13 times as likely to die as the nonsmoking population.21 Smokers have higher death rates for chronic bronchitis and emphysema, as well as a higher prevalence of lung function abnormalities, respiratory symptoms, and all forms of chronic obstructive airway disease. Differences between smokers and nonsmokers increase in direct proportion to quantity of smoking. Age of starting, total pack-years, and current smoking status are predictive of COPD mortality. Approximately 15% of smokers develop clinically significant COPD.22 Also significant in terms of risk for COPD and tobacco use is the finding that smoking during pregnancy is associated with low birth weight, and infants with low birth weight appear to have a greater risk of developing COPD.23 Tobacco smoking is not the only cause of COPD, and in some parts of the world it may not even be the major cause due to the role of indoor air pollution and occupational exposure. The prevailing notion that COPD is largely self-inflicted is counterproductive for future research and disease interventions. It is crucial to take into account the fact that not all smokers develop clinically significant COPD. This points to additional factors that determine each individual’s susceptibility. 18 Introduction Secondhand Smoke Smoking and probably passive smoke exposure Occupational Inhalants The impact of occupational exposures in the in childhood compromises lung growth leading to development of COPD is not yet fully known. diminished maximal lung function in young However, it has been established that occupational adulthood. These deficiencies may portend airway exposures to dust, chemicals and some vapors, hyperreactivity in adult life. Passive smoke irritants and fumes are important contributors, exposure is a risk factor for symptoms of cough and especially when the exposures are sufficiently sputum production, and may account for some of intense or prolonged. Miners, firefighters, metal the COPD that develops in nonsmokers.24 The workers, grain handlers, cotton workers, paper mill World Health Organization (WHO) estimates that workers, agricultural workers, construction workers, passive smoking is associated with a 10 to 43% and others employed in occupations associated with increase in the risk of COPD in adults. prolonged exposure to dusts, fumes, or gases have Ambient Air Pollution The role of outdoor air pollution in causing COPD is unclear, and the relative effect of shortterm, high peak exposures and long-term, low-level exposures is yet to be resolved. There is some evidence that particles found in polluted air will increase the total burden of inhaled particles, which may contribute to total risk. There are studies that have shown comparative increases in chronic respiratory symptoms and pulmonary function abnormalities among subjects living in communities with significant outdoor air pollution. Indoor air pollution from biomass fuel has been established as a risk for the development of COPD. This exposure is seen in environments where biomass fuel is used for cooking and heating in poorly vented dwellings, resulting in high levels of been seen to develop significant airflow obstruction, reduced lung function and respiratory symptoms.26 A study of 3,380 British coal miners showed that there was clinically significant respiratory dysfunction due to inhalation of coal dust, leading to COPD, which was independent of the contribution of smoking to incidence of disease among the subjects.27 Grain dust exposure has also been determined to be a risk for both smokers and nonsmokers.28 These occupational exposures can cause COPD independently of tobacco smoking and increase the risk in the presence of concurrent tobacco smoking by increasing airway hyperresponsiveness. A recent study found that in the United States, 19% of COPD overall could be attributed to occupational hazard with 31% of COPD cases among never smokers being work related.29 25 indoor particulate matter. Arizona Comprehensive Lung Disease Control Plan 19 Alpha1-antitrypsin Deficiency (AAT) individuals with COPD, and adults and adolescents This is the only genetic abnormality that is with asthma (an estimated 20 million Americans) be known to lead to COPD. Severe AAT deficiency tested for Alpha-1. A simple blood test can leads to premature emphysema, often with chronic determine whether a person has low levels of the bronchitis and occasionally with bronchiectasis. It protective protein AAT. Also, a DNA-based cheek is estimated that this condition is responsible for swab test has been recently developed to aid in less than 5% of the emphysema cases in the U.S.. diagnosis. Alpha-1 related emphysema is caused by an 20 The onset of Alpha-1 related emphysema inherited lack of a protective protein called alpha-1 symptoms often appear between ages 32 and 41 antitrypsin (AAT). In normal and healthy individ- years but may appear later. The early age at which uals, AAT protects the lungs from a natural enzyme the disease is present and the fact that the disease called neutrophil elastase. Neutrophil elastase is an most frequently appears in the lower, rather than the enzyme that normally serves a useful purpose in upper, lung regions helps distinguish Alpha-1-related lung tissue – it digests damaged or aging cells and emphysema from other types of emphysema. bacteria in order to provide for healing. However, Evidence shows that smoking significantly once it is done digesting those proteins, it does not increases the risk and severity of emphysema in stop, and attacks the lung tissue. Alpha-1-antitrypsin, AAT deficient individuals and may decrease their in sufficient amounts, will trap and destroy the life span by as much as 10 years.30 neutrophil elastase before it has a chance to begin Hyperresponsive Airways (Asthma) damaging the delicate lung tissue. If allowed to progress, this form of emphysema becomes chronic and lung tissue continues to be destroyed; eventually it is fatal if the progress is not slowed down or halted. It is estimated that there are 100,000 Americans today who were born with Alpha-1 deficiency. Alpha-1 related emphysema might afflict a majority of these individuals. However, AAT deficiency is often under diagnosed or misdiagnosed. As many as 3% of individuals with chronic obstructive pulmonary disease (COPD) may have undiagnosed Alpha-1 deficiency. Worldwide, it is estimated that 116 million people (25 million Americans) are carriers of the disease. WHO recommends that all Asthma, nonspecific airway hyperresponsiveness and atopy (the genetic tendency to develop the classic allergic diseases – atopic dermatitis, allergic rhinitis or hay fever, and asthma) may possibly play a role in COPD. This relationship was originally proposed in 1960 by Orie and colleagues who were in the Netherlands, and thereby given the name “the Dutch hypothesis.”31 Evidence is steadily accumulating that this hyperresponsiveness is predictive of an accelerated rate of decline of lung function in smokers. How these trends are related to the Introduction development of COPD is still unknown. Airway age-adjusted death rate in whites (44 per 100,000) hyperresponsiveness may also develop after was 1.6 times greater than the rate in blacks (28 per exposure to tobacco smoke or other environmental 100,000). The highest prevalence rates were in the insults and thus may be a result of smoking-related over age 65 population for whites, and in the 45 to airway disease. 64 year old age group for blacks. Black women had Infections There is an association of severe childhood infections with reduced lung function and increased respiratory symptoms in adulthood. This may be explained by an increased diagnosis of severe infections among children with underlying airway hyperresponsiveness, which as discussed above may itself be a risk factor. Also, viral infections may be related to another risk factor such as birth weight. The rate of infections in childhood is also directly related to the amount of exposure to secondhand smoke. Among adults, it has been established that HIV infection accelerates the onset of smokinginduced emphysema.32 Demographic Status Sex: Although the rates of COPD deaths have historically been higher in males than females, beginning in 2000, women in the United States have exceeded men in the number of deaths attributed to COPD. In 2002, over 61,000 females died compared to 59,000 males.33 This has been attributed to the increasing use of tobacco among females, and some studies have suggested that women are more susceptible than men to the effects of tobacco smoke.34 Race: COPD is, as of now, the only lung the lowest age-adjusted death rates with 19 per 100,000. Hispanics (male and female aggregated) had an age-adjusted mortality rate of 19 per 100,000, which is markedly lower than the other ethnic groups.35 Socioeconomic Status: There is evidence that the risk of developing COPD is inversely related to socioeconomic status. One correlation that has been documented is the relationship to malnutrition. Because lower serum levels of the major antioxidant vitamins exist, the development of COPD may be more prevalent among those who do not have proper nutrition available. Oxidant injury is believed to be one of the mechanisms of alveolar and airway damage, so a diet deficient in antioxidants could be a risk factor. There is also an association with reduced food intake and levels of antioxidant vitamins in smokers as compared with nonsmokers linking the risk of smoking and COPD. Prevalence rates of tobacco use are also indirectly related to socioeconomic status throughout the world, as is the incidence of exposure to other inhaled pollutants such as biomass fuels.36 The relationship between social position and respiratory mortality may also be attributed to housing conditions, exposure to occupational pollutants, and childhood exposure to indoor air pollution. disease in which the white population has higher age-adjusted death rates than blacks. In 2002, the Arizona Comprehensive Lung Disease Control Plan 21 According to the U.S. Department of Health and The diagnosis requires spirometry (a test of Human Services, National Health Interview Survey pulmonary function); post-bronchodilator (after the of 2002, Table 3 substantiates the link between administration of an inhaled bronchodilator) socioeconomic status and the incidence of COPD. FEV1/FVC <0.7 (a value comprised of the ratio of Diagnosis and Staging the forced expiratory volume in one second of expi- Diagnosis of COPD should be considered in any patient who has any combination of the following: • symptoms of cough ration over the forced vital capacity) confirms the presence of airflow limitation that is not fully reversible. Spirometry should be obtained in all persons • sputum production with the following history: • dyspnea • exposure to cigarettes and/or environmental or • history of exposure to risk factors for the disease occupational pollutants (especially smoking). TA B L E 3 Age-adjusted percents (with standard errors) of selected respiratory diseases among persons 18 years of age and over. 37 22 Characteristic Emphysema Chronic Bronchitis Less than H.S. diploma 3.5 (0.29) 6.3 (0.47) H.S. diploma or G.E.D. 1.8 (0.16) 5.4 (0.29) Some College 1.5 (0.16) 5.1 (0.28) Bachelor’s degree or higher 0.8 (0.13) 2.7 (0.23) Less than $20,000 3.1 (0.23) 6.9 (0.47) $20,000-$34,999 1.7 (0.22) 5.6 (0.40) $35,000-$54,999 1.5 (0.21) 4.4 (0.34) $55,000-$74,999 1.2 (0.26) 4.9 (0.58) $75,000 or more 0.7 (0.23) 2.9 (0.35) Poor 3.5 (0.36) 8.3 (0.64) Near Poor 2.4 (0.25) 5.9 (0.41) Not Poor 1.2 (0.10) 4.0 (0.18) Education: Family Income: Poverty Status: Introduction • family history of chronic respiratory illness and how quickly, the lungs can be emptied. It is • presence of cough, sputum production or dyspnea. easy to administer, takes only a few minutes to complete, and is noninvasive. It can be conducted Spirometric Classification in the primary care physicians’ office with a Spirometric classification has proved useful in spirometer, a relatively inexpensive device. Patients predicting health status, utilization of healthcare take a deep breath and exhale into the spirometer as resources, and development of exacerbation and hard and fast as they can for a minimum of six mortality in COPD. It is intended to be applicable seconds. The spirometer is connected to a computer to populations and not to substitute clinical that records the volume of air exhaled in one second judgment in the evaluation of the severity of disease (FEV1) and the total amount of air exhaled in a in individual patients.38 forced maneuver (FVC). The FEV1/FVC ratio is Spirometry is as important for the diagnosis of the primary measurement in identifying an COPD as blood pressure measurements are for the obstructive impairment of the airways, and is also diagnosis of hypertension. Testing with spirometry used to monitor the progression of COPD.39 determines the presence and severity of the airway obstruction in COPD, by measuring how effectively, It is accepted that a single measurement of FEV1 incompletely represents the complex clinical consequences of COPD because: 1) many patients 23 TA B L E 4 Severity Spirometric general classification Postbronchodilator FEV1/FVC FEV1 % predicted >0.7 ≥ 80 Mild COPD ≤ 0.7 ≥ 80 Moderate COPD ≤ 0.7 50-80 Severe COPD ≤ 0.7 30-50 Very severe COPD ≤ 0.7 <30 At risk Patients who: smoke or have exposure to pollutants have cough, sputum or dyspnea have family history of respiratory disease FEV1: forced expiratory volume in one second; FVC: forced vital capacity. Arizona Comprehensive Lung Disease Control Plan are practically asymptomatic; 2) persistent cough breathlessness or has to stop for breath when and sputum production often precede the develop- walking at own pace on the level. ment of airflow limitation and, in others, the first symptom may be the development of dyspnea with previously tolerated activities; and 3) in the clinical course of the disease, systemic consequences, such as weight loss and peripheral muscle wasting and dysfunction, may develop. Due to these and other factors, a staging system that could offer a composite picture of disease severity is highly desirable, although it is currently unavailable. However, spirometric classification is useful in predicting outcomes such as health status and mortality, and should be evaluated. In addition to the FEV1, the Body Mass Index (BMI) and level of dyspnea have proved useful in predicting outcomes such as survival and it is 24 recommended that they be evaluated in all patients. BMI is easily obtained by dividing the weight (in kg) over the height (in m2). Values <21 kg/m-2 are associated with increased mortality. Functional dyspnea can be assessed by the Medical Research Council dyspnea scale: 0: not troubled with breathlessness except with strenuous exercise. 1: troubled by shortness of breath when hurrying or walking up a slight hill. 2: walks slower than people of the same age due to 3: stops for breath after walking ~ 100m or after a few minutes on the level. 4: too breathless to leave the house or breathless when dressing or undressing.40 Treatment/Management An effective treatment program for COPD includes these four components of care: (1) assess and monitor disease, (2) reduce risk factors, (3) manage stable COPD by both pharmacologic and non-pharmacologic interventions, and (4) manage acute exacerbations. Spirometry is a key tool in the assessment and monitoring of disease as is continuous appraisal by healthcare providers of patients’ symptoms and health status. The other three components are addressed in the following sections. Tobacco Smoking Cessation Since smoking is the predominant risk factor for COPD, and the majority of patients are smokers when they are diagnosed, the first line of treatment for the disease is smoking cessation. Cessation of smoking is the single most effective and cost effective intervention to retard the progression of COPD, and improve the quality of life and activity level of the patient. Cigarette smoking is an addiction and a chronic relapsing disorder regarded as a primary disorder by the United States Department of Health and Human Services Guidelines and by the WHO. Therefore, treating tobacco use and dependence should be regarded as a primary and specific intervention. 26 Introduction Preventing the development and progression of COPD can be regarded as one of the secondary Pharmacologic Interventions Effective medications for COPD are available effects prevented by treating the primary disorder, and all patients who are symptomatic merit a trial of because although cigarette smoking is the single drug treatment. Therapy with currently available most important cause of COPD, it is also a major medications can reduce or abolish symptoms, risk factor for many other diseases including increase exercise capacity, reduce the number and atherosclerotic vascular disease, cancer, peptic ulcer severity of exacerbations, and improve health status. and osteoporosis. Unfortunately, at present no drug treatment has Smokers experience an accelerated rate of decline in lung function. Individual susceptibility, however, varies greatly and depends on a complex been shown to modify the rate of decline of lung function. The inhaled route is preferred when both inhaled interaction of many genetic and environmental and oral formulations are available. Smaller doses factors. It is often stated that 15% of smokers will of active treatment can be delivered directly with develop COPD. This dramatically underestimates equal or greater efficacy and with fewer side effects the impact of smoking because the majority of when administered by inhalation. smokers will develop loss of lung function, and Patients must be educated in the correct use of reduced lung function, at any level, is predictive of whatever inhalation device is employed. Significant increased mortality. numbers of patients cannot effectively coordinate Many smokers with undiagnosed COPD have their breathing with a metered dose inhaler (MDI) symptoms. It is necessary to identify and properly but can use a breath-activated inhaler, a dry powder diagnose individuals earlier in the course of the inhaler (DPI) device or a spacer chamber. The latter disease when physiological limitation and may be useful when inhaled corticosteroids are symptoms are milder. Quitting smoking can slow administered, as it reduces the oropharyngeal the progressive loss of lung function and can reduce deposition and subsequent local side effects symptoms at any point in time. Yet, the beneficial associated with these drugs. impact of smoking cessation on the natural history Medications of different classes have been found of COPD is greatest the earlier cessation is to be useful in treating COPD and can be used in achieved. Adolescents who quit smoking will have combination. The overall approach to managing increased lung growth. 41 stable COPD involves a stepwise increase in treatment, depending on the severity of the disease. Bronchodilators are a class of medications that relax the muscles around the bronchi to allow easier breathing. They are typically indicated for the relief Arizona Comprehensive Lung Disease Control Plan 27 of bronchospasm, which are contractions of the anticholinergics are minimally absorbed, resulting in smooth muscle in the walls of the bronchi and bron- relatively few side effects. Some common side chioles that cause the airways to constrict or narrow. effects of ipratropium bromide, an inhaled anti- Anticholinergic bronchodilators fall into this class cholinergic therapy, include cough and nervousness. of COPD medications, as do short-acting beta2- Anticholinergic bronchodilators, as a class, are agonists, long-acting beta2-agonists, methylxan- the number one prescribed bronchodilator used in thines (e.g., theophylline), and a combination of an the treatment of COPD. Currently, the leading anti- anticholinergic bronchodilator and a short-acting cholinergic medication prescribed by physicians is beta2-agonist. ipratropium bromide. It is sold alone under the All major guidelines for COPD management brand name ATROVENT, Inhalation Aerosol or in recommend beginning treatment with aerosol bron- combination with albuterol sulfate under the brand chodilators, which are inhaled directly into the name COMBIVENT, Inhalation Aerosol. lungs and have few side effects. In response to irritants such as cigarette smoke, 28 Beta2-agonists work via part of the nervous system that controls muscle tissue around the the body produces a chemical “messenger” called airways. They work by stimulating receptors in the acetylcholine that induces the airways to constrict. sympathetic nervous system, leading to dilation of Anticholinergic bronchodilators are the only air passages. Two types of beta2-agonists are medications that act by blocking acetylcholine, available: short-acting beta-agonists and long- thereby relaxing the muscle tissue and keeping the acting beta-agonists. airways open. Anticholinergic medications work via Short-acting beta2-agonists are recommended part of the parasympathetic nervous system, which for patients with COPD who experience intermittent controls airway size. In addition to helping COPD symptoms. They are also used as a “rescue” patients take fuller breaths, maintenance use of anti- medication to fend off an impending attack of cholinergic medication may also help lower the shortness of breath. Short-acting beta2-agonists are incidence of acute exacerbations in COPD patients. typically prescribed along with anticholinergics to Anticholinergics are most often administered open up the airways of COPD patients with contin- through metered-dose inhalers, or “puffers,” as they uing symptoms. The short-acting beta2-agonist are commonly called. The effects of the medication most commonly prescribed by physicians is generally last from four to six hours, so physicians albuterol. In clinical studies, the most common typically prescribe use four times a day. Inhaled side effects of albuterol included tremor, nausea, tachycardia, palpitations and nervousness. Long-acting beta-agonists are bronchodilators that are taken twice a day and, like short-acting beta-agonists, work via part of the nervous system that controls muscle tissue around the airways. Introduction Long-acting beta-agonists are often prescribed for nighttime breathing problems because they provide up to 12 hours of relief. Patients using benefits that go beyond bronchodilation, and it is still an important part of COPD management. Theophylline is taken orally once or twice a day, long-acting beta-agonists need to be reminded to so it may be particularly valuable for noncompliant continue using their short-acting beta-agonist for patients who cannot optimally use aerosol therapy. “rescue” therapy, because long-acting beta-agonists The dosage should be adjusted to reach a do not work as quickly and are indicated for use only therapeutic serum level, so blood levels should be twice a day. The most common side effects seen with monitored. However, some patients experience side use of long-acting beta-agonists by patients with effects even at low serum levels. The most common COPD include headache, upper respiratory tract side effects seen are nausea, vomiting, headache and infection, nasopharyngitis and cough. insomnia. Combination bronchodilators are the combina- Currently, inhaled corticosteroids are not tion of an anticholinergic and short-acting indicated for the treatment of COPD. They are the beta2-agonist, and work via the part of the nervous cornerstone of asthma therapy, but have a limited system that controls airway size, as well as the part role in the maintenance of lung function in patients that controls muscle tissue around the airways. with COPD. Only about 10 % of patients with Increased efficacy is seen with this combination COPD show a significant improvement in lung agent over the individual components, without an function when treated with corticosteroids. The increase in side effects. The most common side reason is that different mediators cause inflamma- effects include bronchitis, upper respiratory tract tion in asthma and COPD. The mediators that cause infection and headache. inflammation in COPD have only limited respon- Another bronchodilator used in the treatment of siveness to corticosteroids, while those mediators COPD is theophylline, which is taken orally. responsible for inflammation in asthma are Theophylline affects many parts of the body, dramatically affected by inhaled corticosteroids. including muscle tissue and the heart. It works by Surveys of clinicians' prescribing habits, opening up the airways, increasing muscle however, have shown little difference in the use of endurance, and decreasing muscle fatigue. At one inhaled corticosteroids for asthma patients and for time, theophylline was the most widely prescribed COPD patients. Guidelines for the treatment of COPD medication, but it has lost favor because of COPD suggest that because inhaled corticosteroids side effects. However, theophylline may have play only a minor role in the maintenance treatment of COPD and may produce systemic side effects, they should be reserved for patients whose symptoms are not optimally controlled with Arizona Comprehensive Lung Disease Control Plan 29 bronchodilators. This subgroup of patients should receive inhaled or oral corticosteroids for a trial Although there is debate about its benefits, the period. If a significant objective clinical response pneumococcal vaccine is also currently recom- is not achieved, corticosteroids should be discon- mended for all COPD patients. This vaccine is not tinued. When a benefit is observed with oral given annually, and there is concern about the rate corticosteroids, the dose should be tapered to the of decline in immune response and immune lowest possible dose. At that point, a trial of an reactions in immunocompetent patients.43 inhaled corticosteroid should be initiated. The most Long term oxygen therapy (LTOT) is used to common side effects of inhaled corticosteroids treat patients with chronic hypoxemia (low levels of include upper respiratory infection, headache and oxygen being carried by the blood). It can improve pharyngitis. survival, exercise tolerance, sleep efficiency, and Antibiotics may be given to patients with COPD 30 vaccine or are allergic to eggs. cognitive performance in these patients. The use of for acute bacterial infections of the respiratory tract, LTOT can be continuous, with activity only, or including sinusitis, acute bronchitis and some types during sleep, depending on the needs of the patient. of pneumonia. Antibiotics are also used to treat There are established guidelines for prescribing exacerbations when symptoms of infection are oxygen for patients. These guidelines are based on present, such as fever, increased cough and sputum the values of arterial blood gases or pulse oximetry changes.42 testing at rest and with activity (if tolerated by the COPD patients are at high risk for respiratory patient). All prescriptions for oxygen should tract infections; therefore prophylaxis via include the source of oxygen (gas, liquid or concen- vaccination is recommended for this population. trator), the method of delivery, duration of use, and Vaccination can reduce the incidence and severity specific flow rates for rest, exercise and sleep.44 of bronchial infections with which COPD morbidity and mortality is closely associated. Annual vaccine against influenza, with vaccine formulation and potency revised yearly is essential. Amantadine and similar drugs can be used for prophylaxis during high-risk periods for influenza for patients who either have not been vaccinated in time or for patients who have had prior allergic reactions to the Non-pharmacological Interventions These include pulmonary rehabilitation services, which may require long-term adherence by the patient from diagnosis throughout the course of their disease, and surgical options, which are not widely used, but have had some beneficial outcomes in select patients. Pulmonary rehabilitation is a multidisciplinary program of care that is individually tailored and designed to optimize the COPD patient’s physical and social performance and autonomy. Introduction Comprehensive pulmonary rehabilitation generally Surgical interventions for COPD are limited to includes exercise training (endurance and strength), those few selected patients who might benefit from education (promoting disease awareness and the procedure, are healthy enough to withstand the self-management), psychosocial and behavioral trauma of the surgery, and who will be compliant intervention (support groups and referral to with and able to tolerate aftercare. These surgeries behavioral health services), nutritional therapy and include bullectomy, lung volume reduction surgery, outcome assessment. Smoking cessation interven- and lung transplantation, which may result in tion is an obviously important component of the improved spirometry, lung volume, exercise pulmonary rehabilitation process for smokers. capacity, dyspnea, health-related quality of life and Pulmonary rehabilitation is usually coordinated by an experienced healthcare professional, such as a possibly survival in highly selected patients. • Bullectomy: This is a procedure in which a large registered nurse, physical therapist or respiratory bulla, which does not contribute to gas exchange, therapist. Also involved is a multidisciplinary team is removed to alleviate local symptoms such as that varies between programs, but often includes hemoptysis, infection, or chest pain, and to allow physicians, nurses, respiratory therapists, physical re-expansion of the compressed lung region. It therapists, occupational therapists, psychologists, can be done thoracoscopically. dieticians and social workers. Pulmonary rehabilitation results in improvements in multiple outcome areas of considerable importance to the patient, including dyspnea, exercise ability, health status and healthcare utilization. These positive effects occur despite the fact that it has a minimal effect on static pulmonary • Lung Volume Reduction Surgery: This is a surgery in which parts of the lung are resected to reduce hyperinflation. This results in making respiratory muscles more effective by improving their mechanical efficiency. This procedure also increases the elastic recoil pressure of the lung and thus improves expiratory flow rates. function measurements. This reflects the fact that much of the morbidity from COPD results from secondary conditions, which are often treatable if recognized. Examples of these treatable conditions are cardiac deconditioning, peripheral muscle dysfunction, and a reduction in total and lean body mass anxiety, and poor coping skills.45 • Lung Transplantation: This is a highly limited procedure due to cost, availability of donor organs, and selectivity of appropriate candidates. There is also considerable question about the long-term survival benefits, although it has been shown to increase functional capacity and improve quality of life.46 Arizona Comprehensive Lung Disease Control Plan 31 Exacerbations An exacerbation of COPD is an event that changes the natural course of the disease so that symptoms become more severe, and a change in management of the disease is warranted. The causes of exacerbations may be infectious or non-infectious, and in some instances, the reason for worsening of symptoms remains unknown. Severity of exacerbations varies, and prognosis often depends on the stage of advancement of the disease and the existence of comorbid conditions. Common comorbid conditions associated with poor prognosis in exacerbations are congestive heart failure, coronary artery disease, diabetes mellitus, renal and liver failure. Most often, exacerbations can be managed by primary care physicians on an 32 outpatient basis. Corticosteroids and antibiotics are used widely in the management of COPD exacerbations. It is essential that patients understand how to monitor their symptoms and detect when there is a change, so that they can immediately seek medical attention. In some instances, exacerbations can be so severe that hospitalization is required, even including non-invasive or invasive mechanical ventilation. There are times when a patient cannot be removed from ventilation after an exacerbation and becomes ventilator dependent. Some patients who are dependent on mechanical or assisted ventilation can be discharged from the hospital on ventilators and can continue to be managed at home. This requires coordinated support from caregivers and health professionals, but is less costly than hospitalization or extended care facilities, and can provide an improved quality of life for patient and family. When COPD patients experience an exacerbation, causing them to interact with healthcare professionals and institutions, it can be seen as an opportunity for evaluation, education, and follow-up. Unfortunately, approximately one third of patients with acute exacerbations have recurrent symptoms within 14 days, and 17% relapse and require hospitalization.47 Identifying those patients at risk for relapse and providing adequate follow-up can reduce these rates. Efficacy of disease treatment and management of the COPD patient with an exacerbation should be measured not just by recovery from exacerbations, but also by exacerbation-free intervals, resource utilization, and improved quality of life.48 Objectives Objectives Epidemiology and Research this umbrella term may or may not include asthma, and chronic bronchitis is often confused with acute Objectives bronchitis. Other chronic obstructive lung diseases 1. Establish a surveillance system to accurately such as obliterative bronchiolitis and cystic fibrosis track the mortality and morbidity of COPD in are excluded since they have known etiology or Arizona, and also measure the impact on the specific pathology.49 Other nomenclature for COPD economy of the state. as defined in this paper include Chronic Obstructive 2. Support research into COPD etiology and clinical Lung Disease, or Chronic Lower Respiratory management, as well as healthcare policies and Disease, which could include diseases other than outcomes particularly as the activities relate to emphysema and chronic bronchitis. state issues. Mortality data for COPD is also underestimated because it is more likely to be cited as a contribu- Rationale It is essential that COPD prevalence be assessed and monitored as a foundation for managing the disease. Disease surveillance is difficult and expensive, but in regard to COPD, accurate epidemiological data is particularly elusive. Prevalence and morbidity data, when available, greatly underestimate the total burden of COPD because the diagnosis is usually delayed until it is clinically apparent and moderately advanced. The term Chronic Obstructive Pulmonary Disease is imprecise and variably defined, and is not tory rather than as an underlying cause of death if it is cited at all. This is also a problem with hospitalization data.50 Research progress in the field of COPD has been slow and mostly focused on the association of COPD with cigarette smoking. There has not yet been significant research leading to a reduction in COPD prevalence or morbidity, to the development of any therapy proven to modify the disease process itself, or to an adequate understanding of how risk factors other than cigarette smoking may contribute to COPD. often used in health surveys. The diseases under Arizona Comprehensive Lung Disease Control Plan 35 Understanding why only certain smokers c. Cost of COPD (e.g. direct and indirect costs develop COPD not only illuminates the mechanisms including AHCCCS, medical care billing and of the development of the disease, but also might pharmacy costs). allow for the targeting of intensive smoking interventions to individuals at highest risk while enhancing the effectiveness of these interventions. d. Prevalence of exacerbations. e. Disparities in access to healthcare for COPD in target populations. There are also variations in the rate of decline in lung function among individuals with COPD that suggests intrinsic or environmental factors influencing disease course, which may differ from those determining susceptibility to disease. Recommended objectives for future research their families. • Establish a standardized case definition of COPD, and establish criteria for the measurement of COPD morbidity and mortality. include description of the disease process, disease • Collect accurate, timely data on prevalence, pathogenesis, advanced therapeutic modalities and morbidity, mortality, and cost statistics for clinical studies to validate or revise current clinical COPD. practices.51 36 f. Quality of life for people with COPD and Objective 1. Establish a surveillance system to accurately track the mortality and morbidity of COPD in • Create an infrastructure for emergency department and hospitalization data to be obtained from all medical facilities statewide including federal and tribal and Bureau of Indian Affairs institutions. Arizona, and also measure the impact on the • Collect data and do analysis on the effect of economy of the state. COPD on work ability, efficiency, and job Strategies choice, as well as the effect of occupational • Develop surveys to collect data not available exposures on COPD risk. through existing data sources. • Use existing and new data sources to assess (by demographic, geographic, and socioeconomic variables): a. COPD disease severity (e.g. hospitalization rates, mortality rates, emergency department visit rates). b. COPD management and treatment patterns (e.g. prescription utilization patterns). • Ensure adequate resources to develop and/or maintain new and/or existing surveillance systems. • Disseminate reports based on acquired data to community stakeholders. Objectives Objective 2. Support research into COPD etiology and clinical management, as well as healthcare policies and outcomes particularly as the activities relate to state issues. • Perform research studies to determine the necessary elements and best timing for pulmonary rehabilitation, including cost/benefit analyses. • Increase participation in clinical trials through education of patients. Strategies • Improve data sources to increase understanding of COPD risk factors and evaluate effectiveness Treatment and Management of interventions. • Encourage basic and clinical research to develop Objectives new and effective disease modifying therapies 3. Improve early detection and diagnosis of COPD. that will decrease the loss of lung function, 4. Promote better care for patients with COPD in restore lung function, and lengthen lifespan. Arizona according to established guidelines. • Identify intermediate end-points and biomarkers 5. Educate healthcare providers to manage patients for the effective and efficient translation of basic with COPD to increase longevity and quality of research findings to clinically relevant outcomes. life and reduce exacerbations of the disease. • Increase research related to occupational and environmental causes and contributors to COPD. • Foster research that addresses the risk and 37 6. Establish physician-patient partnerships through education and management. 7. Improve access to pulmonary rehabilitation resiliency of smokers in the development of programs for Arizonans with COPD in order to COPD and the variation in susceptibility to prevent and forestall premature morbidity and COPD and disease progression that distinguishes mortality. the 10 to 20% of smokers of one pack per day or more who eventually develop clinically significant airflow limitation from other tobacco smokers who never develop airway dysfunction. • Encourage research funding to develop and Rationale Currently in the U.S., mortality due to chronic obstructive pulmonary disease is ranked number four and is projected to rise to number three by evaluate the role of chronic disease management 2020. The number of patients with physician programs for COPD. diagnosed COPD is estimated at 10 million, the number of people with abnormal lung function is estimated at 24 million. The underdiagnosis of lung disease in the U.S. may approach 14 million.52 Arizona Comprehensive Lung Disease Control Plan Healthy People 2010 describes the following opportunities to help meet its objectives for Objective 3. Improve early detection and diagnosis of COPD. improving health for individuals with COPD: “Primary care physicians are in a key position to Strategies provide optimal care to patients with COPD and to • Spirometry capability should be available to all provide counseling during clinical or health center visits to patients who smoke. Effective tests are • Develop a practical and feasible list of indica- available to screen patients for COPD, and primary tions for spirometry and an easily understandable care physicians need to be trained in the latest algorithm for interpretation and action. methods to detect and treat the disease.” Since COPD can remain asymptomatic for 20 to • Encourage primary care providers to perform an office spirometry test for all patients over 45 30 years before clinical symptoms appear, and by years old who report smoking tobacco, or anyone the time it is diagnosed, 75% of lung function has of any age who has one of the cardinal symptoms been lost, it is essential that early diagnosis and of COPD: chronic cough, excess mucus (sputum) intervention occur in those people at risk for COPD. production, dyspnea on mild exertion out of Early diagnosis coupled with smoking cessation can proportion to age, or wheezing. improve lung function and retard the rate of decline 38 healthcare professionals. • Develop a consensus for severity assessment and deterioration of quality of life. Preliminary criteria, and promote consistent utilization of studies have indicated that knowledge of abnormal criteria by healthcare providers. lung function can be a powerful motivator in smoking cessation and that smokers who are tested Objective who have normal lung function may be motivated 4. Promote better care for patients with COPD in by relief that smoking has not yet damaged their Arizona according to established guidelines. lungs. Not only COPD, but also risk of lung cancer, Strategies heart attack and stroke is predicted by abnormal • Establish a community standard for COPD spirometry results. The spirometer is a tool for all four of these most common causes of death in the U.S. and the world. The National Lung Health Education Program is promoting patients to including consensus on clinical guidelines to be adopted (i.e. American Thoracic Society, “Standards for the Diagnosis and Care of Patients with Chronic Obstructive Pulmonary Disease”). “Test Your Lungs, Know Your Numbers,” so that spirometric values are as well known as blood type, • Assess current healthcare provider knowledge of established standard clinical guidelines. blood pressure and cholesterol levels, and they are working to educate providers and demystify spirometry, to foster utilization by healthcare professionals.53 40 Objectives • Set measurable clinical standards based on scientifically valid management guidelines. Objective 5. Educate healthcare providers to manage patients with COPD to increase longevity and quality of life and reduce exacerbations of the disease. Objective 6. Establish physician-patient partnerships through education and management. Strategies • Encourage providers to promote healthy living practices to patients such as tobacco cessation, good nutrition, physical activities and regular Strategies • Implement physician education programs that impact behavior change such as reminder systems, standing orders, clinical pathways or vaccinations against influenza and pneumonia. • Create incentives for healthcare professionals to counsel their patients in healthy lifestyle choices, and COPD self-management. protocols, opinion leaders and physician champions, as well as self-monitoring and feedback. • Educate providers to develop and utilize COPD disease management plans to enable their patients to avoid exacerbations of their • Conduct provider education utilizing interactive techniques on diagnosis and management of disease and/or minimize the severity of these exacerbations. COPD. • Coordinate efforts with health plans, medical • Create an incentive program to motivate healthcare providers to participate in educational sessions. Develop interdisciplinary models of COPD care. • Work with healthcare providers to develop providers, government and non-government agencies, families, and other stakeholders to promote, develop, use and disseminate COPD disease management plans for all patients with COPD. models for chronic disease management that are applicable to COPD. • Develop or adopt a COPD education program to certify health educators in Arizona. • Partner with non-profit agencies and community organizations to facilitate provider education. Objective 7. Improve access to pulmonary rehabilitation programs for Arizonans with COPD in order to prevent and forestall premature morbidity and mortality. • Promote the use of COPD management plans as part of comprehensive COPD education programs for providers. Arizona Comprehensive Lung Disease Control Plan 41 Strategies COPD patients absorb a tremendous burden, • Increase awareness of the effectiveness of particularly in the later stages of the disease, when pulmonary rehabilitation among patients with mild exertion is difficult and the patient ceases to be COPD, physicians (both primary care and ambulatory. Support and education for the patient specialists), and policy makers, including and family can improve quality of life, but also AHCCCS (Arizona Healthcare Cost reduces the direct and indirect costs to our society. Containment System). Objective • Address issue of adequate reimbursement for pulmonary rehabilitation services. Patient Education and Quality of Life Issues Objectives 8. Improve self-management knowledge and behavior in people with COPD, their families and other caregivers. Strategies • Develop or promote models for chronic disease management applicable to COPD. 8. Improve self-management knowledge and behavior in people with COPD, their families and other caregivers. 42 • Institutionalize the use of COPD disease management plans modeled after asthma management plans. 9. Provide social support for patients, families, and caregivers impacted by COPD. • Encourage improved patient/provider relationships to enhance COPD education and Rationale Education about COPD and methods for treatment self-management skills. • Develop or identify a clearinghouse of COPD and management are critical in enabling patients to related information and resources which are understand the disease process and provide them available on the Internet. with the knowledge they need to make informed decisions. An effective disease management • Work with community organizations to make COPD education materials available statewide. program that balances nutrition, exercise and behavior modification can help patients cope with Objective symptoms, avoid exacerbations and comorbid 9. Provide social support for patients, families, and conditions and focus on a positive program to caregivers impacted by COPD. prolong quality of life, keeping them active and productive for as long as possible. The families of Strategies • Establish and sustain COPD support groups for patients, families and caregivers. 44 Objectives • Evaluate home care and monitoring in relation to decades to appear greatly contributes to the limited utilization of healthcare resources including perceived risk of tobacco use. A long-term compre- physician offices, emergency departments, hensive tobacco control program which focuses on skilled nursing facilities, and acute care facilities. preventing the initiation of tobacco use among • Include COPD management in workplace wellness and disease management programs. youth and young adults, promoting quitting, and reducing exposure to secondhand smoke is essential to reduce the disability and death related to COPD. Prevention Objectives 10. Promote healthy living practices, which provide the most effective method of preventing COPD (tobacco abstinence, periodic health checks, Environmental exposure to certain inhalants is another cause of COPD. Management of controllable exposure such as workplace regulations of occupational inhalants and policies protecting the public from environmental tobacco smoke can reduce potential risk. When environmental avoidance of unhealthy work environments). exposure is coupled with tobacco use, the total load 11. Reduce exposure to environmental and occupational risk factors to prevent the onset and of inhaled irritants increases the risk of developing the disease exponentially. progression of COPD. Objective Rationale Since 80 to 90% of COPD cases occur in 10. Promote healthy living practices, which provide the most effective method of preventing COPD tobacco users, obviously abstinence from tobacco (tobacco abstinence, periodic health checks, use would vastly decrease morbidity and mortality avoidance of unhealthy work environments). for the disease. In addition, early detection of airway hyperreactivity by healthcare providers during routine health checks can be a tool in motivating tobacco users to quit, thereby preventing the development of COPD and the subsequent progression of the disease. Tobacco addiction is complex and the fact that the devastating health effects caused by tobacco use and secondhand smoke exposure on average take Strategies • Encourage campaigns to emphasize the impact of smoking cessation. • Develop creative approaches to alert young people to the potential of COPD and its causes, especially tobacco use and secondhand smoke. • Increase resources devoted to COPD prevention in the workplace, targeting interventions, and evaluating the effectiveness of those interventions. Arizona Comprehensive Lung Disease Control Plan 45 • Encourage or require third party payers to Disparity support treatments for smoking cessation as a component of COPD treatment. Objective 12. Identify and eliminate disparities in COPD Objective prevention, diagnosis, and management 11. Reduce exposure to environmental and throughout the state. occupational risk factors to prevent the onset and progression of COPD. Rationale The definition of a disparate population group Strategies in relationship to COPD encompasses those at • Partner with state and federal regulatory agencies highest risk to develop COPD, as well as those to manage environmental and occupational risk with COPD who do not have ready access to factors. diagnosis, treatment and management, thereby • Educate patients and caregivers about those 46 causing them to bear a disproportionate burden of environmental and occupational inhalants that morbidity and mortality. Since we have established exacerbate their disease and the avoidance of that the incidence of COPD is highly related to these agents. tobacco use, there is value in defining those groups • Promote public awareness of environmental factors that cause and contribute to COPD. • Disseminate educational materials on occupational risk factors and triggers to employers, employees, healthcare providers and health insurance plans. at highest risk for COPD similarly to those at highest risk for tobacco related health disparities. Therefore, the ADHS/TEPP strategic plan identification of populations at highest risk for tobacco related health disparities is useful as stated: “Disparities (i.e., measurable differences) derive from ingrained patterns of resource allocation (e.g., • Promote clean indoor air quality management plans for all public buildings. services, funding, staffing, equipment, community support, etc.) and prioritization that contribute to • Promote awareness of the effects of secondhand smoke on COPD patients. modes of inequity and social injustice. Among the various Arizona communities, tobacco-related disparities may be characterized by race (a class or kind of people unified by community of interests, habits, or characteristics – African American, Asian, Caucasian, Hispanic), ethnicity (of or relating to large groups of people classed according to common racial, national, tribal, religious, Objectives linguistic, or cultural origin or background – chronic diseases. Although currently COPD African American, specific to Asian region, prevalence is greatest among the white population, multi-Latin American Descent, multi-European the large numbers of non-whites who are at risk and Descent), gender (male, female, possibly who are afflicted with lung disease, as well as the transgender), age, income/class (what one makes many who may be undiagnosed, make this essential does not always reflect community status), health in planning interventions. status, education, sexual orientation, or geographic location, among others.” As discussed previously in the plan, there is evidence that the risk of developing COPD is Strategies • Identify specific populations with increased rates of COPD and/or with limited access to COPD resources. inversely related to socioeconomic status. This tracks the documented trend of prevalence rates of tobacco use, which is also indirectly related to socioeconomic status. The relationship between • Explore constructs contributing to the burden of COPD in identified disparate populations. • Collaborate with community partners to identify social position and respiratory disease may also be and promote available COPD-related resources attributed to housing conditions, poor nutrition, and education to rural and border communities. exposure to occupational pollutants, and childhood exposure to indoor air pollution. Arizonans of lower socioeconomic status are • Develop, promote and disseminate COPD-related resources that are culturally sensitive. • Develop, promote, and disseminate COPD-related least likely to have access to early detection of and resources that meet the needs of all Arizona intervention with COPD and tend to have erratic residents taking into account socioeconomic relationships with healthcare providers, making status, race, education level, language and age. disease management and follow-up inconsistent if it is available at all. They also are least likely to take advantage of state funded tobacco cessation programs. • Working in conjunction with the Arizona Healthcare Cost Containment System, develop a system to aid uninsured residents with COPD to obtain health insurance coverage. Identifying differences in how racial and cultural • Identify emergency assistance programs and groups in our state view and interact with healthcare systems will also be important in establishing programs and methods to influence members of organizations providing free or discounted services, medications, and/or medical equipment statewide. these groups who are at risk or afflicted with • Assist healthcare providers and community healthcare organizations to provide COPD education to all patients diagnosed in Arizona. Arizona Comprehensive Lung Disease Control Plan 47 Collaborative Efforts promote established clinical guidelines, and create a platform for community advocacy and the Objective mobilization and coordination of efforts to combat 13. Foster communication, collaboration and the disease. networking opportunities among patients, Strategies caregivers, healthcare professionals, public health officials, and other stakeholders. • Foster the establishment of community-based healthcare coalitions for COPD, including the Rationale Partnerships are essential in any successful disease control program. For COPD, few professionals. • Develop public-private partnerships with established coalitions and workgroups exist. It is organizations and government agencies that essential that these be created statewide to begin to include, or could be expanded to include, address the seriousness of COPD as a public health projects related to COPD. issue. Collaborative efforts among medical organi- 48 participation of physicians and other healthcare • Bring together COPD stakeholders to continually zations, government agencies, patient groups, and refine, alter, promote and monitor the implemen- policy makers can provide a concerted effort to tation of the COPD state plan. reduce the prevalence and mortality of the disease. By sustaining and expanding a strong network, Advocacy stakeholders can promote unified, consistent messages to raise awareness of COPD. By bringing together healthcare professionals, Objective 14. Advocate and support policies to reduce the patient organizations, governmental agencies, and prevalence of tobacco use and secondhand other stakeholders, efforts can be made to define smoke exposure among Arizonans. barriers, create and implement programs for Rationale prevention and early detection, promote better care Policies that support and promote tobacco for patients, reach undiagnosed patients with abstinence and clean air quality ordinances are information, and improve the quality of life for important in the overall reduction of COPD those impacted by the disease. morbidity and improvement of quality of life of A well-established coalition can also stimulate persons with the disease. Increased awareness of scientific research to better understand COPD, seek COPD as an important health problem by decision new treatments for the disease, as well as prevention strategies. There also would be opportunities to define and evaluate programmatic best practices, Objectives makers can set the stage for such measures. The Public Awareness relationship between tobacco use and the incidence of COPD justifies public policy intervention due to Objective the high direct medical costs and indirect disability 15. Increase awareness of the medical community, costs associated with the disease. Voluntary worksite policies and local ordinances promoting smoke-free environments have spurred public health officials and the general public that COPD is a serious public health problem in Arizona. interest in a statewide law that would protect all Arizonans from the dangers of environmental tobacco smoke while stressing importance of tobacco abstinence. Additionally, providing a consistent minimal level regulation for smoking in public places would alleviate confusion and competition among neighboring communities. Rationale COPD has generally been overlooked by the public and health community, especially in relationship to its significant impact on mortality and morbidity worldwide. Some of the reasons for this may be incomplete information about the disease and its prevalence. It is also a disease that Strategies remains undetected until it is moderately advanced, • Educate policy makers about the burden of its symptoms being attributed to aging or poor COPD in Arizona and the risk relationship of physical conditioning, with a long drawn out course tobacco use and secondhand smoke exposure. towards decline and death as compared to more • Public policies that promote clean indoor air quality. • Statewide smoke-free initiative to prohibit smoking in all enclosed public places. dramatic and sudden life-threatening illnesses. The fact that smoking tobacco causes 80 to 90% of COPD cases has caused COPD to be viewed as self-inflicted, and thereby less important than other chronic diseases, especially in regard to resources allocated to provide surveillance, conduct research, and improve lifestyle for patients and families. Difficulties in determining the human and economic burden of COPD have previously been discussed within this plan, as well as confusion over the definition of the disease. Another challenge to positive patient outcomes is the prevalence of later stage diagnosis. In order to raise awareness of COPD, a consistent, unified message needs to be developed Arizona Comprehensive Lung Disease Control Plan 49 and promoted through educational programs, stakeholder participation in assessing and modifying workshops, and special events. The increasing the plan as workgroups see fit. Stakeholders may burden of COPD will not be arrested until include among others, medical and public health knowledge and public awareness of the disease is professionals, patients and caregivers, employers, promoted, thereby increasing the demand for health insurance providers, and representatives from accurate surveillance and improved public health the AHCCCS program. This comprehensive plan is interventions. In order to do this, committed a framework, and in order to refine and reach organizations and individuals must be brought toward implementation, a formal collaboration together to exchange information and plan across multiple organizations and disciplines needs mobilization to raise the profile of this forgotten to be formed to set priorities of action, mobilize disease and bring attention to these critical issues. support to implement priorities, and put in place Strategies • Develop a COPD awareness campaign with a clear, consistent message about COPD, tailored an evaluation system to monitor progress and periodically reassess priorities. In addition, the plan should be updated and revised on a continuous basis to ensure the plan is addressing relevant issues to different constituencies. and meeting the needs of persons with COPD • Target the awareness campaign to a variety of groups, including health professionals, decision 50 makers, providers, payers, lay public, and patients. • Promote awareness of occupational and environmental conditions that present risk factors for the development and exacerbation of COPD cases. Future Directions The ultimate goal of creating a comprehensive COPD disease control plan should be to coordinate existing services and available resources, identify gaps in services, and provide a guide for future endeavors. In order to achieve this goal, future steps for this comprehensive COPD disease control plan for the State of Arizona should include in Arizona. References References 1 Murray CJL, Lopez AD. Evidence-based health policy lessons from the global burden of disease study. 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