COPD Hits Rural America Harder: Prevalence, Hospital Stays and Deaths, 2015

Chronic obstructive pulmonary disease (COPD) — which includes emphysema and chronic bronchitis — accounts for most deaths from chronic lower respiratory diseases, the third leading cause of death in the United States in 2015. That year, 15.5 million adults said they had been diagnosed with it, there were about 335,000 Medicare hospitalizations for it, and 150,350 people died of it. CDC found that the farther people lived from big cities, the heavier the burden.

Credit: CDC, Morbidity and Mortality Weekly Report*.*

From city to country

Prevalence, hospitalizations and deaths were all significantly higher in rural areas than in micropolitan or metropolitan areas. County estimates of prevalence ranged from 3.2% to 15.6%. Seven states were in the top quarter on all three measures, and four of them — Arkansas, Kentucky, Mississippi and West Virginia — were also in the top quarter for share of residents living in rural areas (18% or more).

Why rural residents may be at higher risk

The major risk factors for COPD are tobacco smoke, environmental and occupational exposures, respiratory infections and genetics; older age, low income and a history of asthma are also linked to it. Rural populations have more people who have smoked, more exposure to secondhand smoke with less access to programs to quit, and more uninsured and low-income residents, who may have trouble getting early diagnosis and treatment. Rural respiratory hazards include mold spores, organic toxic dust and nitrogen dioxide.

Barriers to care

COPD care aims to slow the loss of lung function, improve exercise tolerance and prevent flare-ups, through pulmonary rehabilitation, oxygen and medicines, plus quitting smoking, flu and pneumococcal vaccines, physical activity and fewer harmful exposures. In rural areas, cultural attitudes toward seeking care, long travel, missing services and cost get in the way, and lung specialists are hard to reach, so primary care providers handle most COPD.

• 27% of adults with COPD symptoms in 2016 had not talked to a doctor about them.
• 71% of primary care physicians said they would use spirometry to assess COPD symptoms, but cited barriers: patients not reporting symptoms or smoking, poor adherence, more urgent health problems and test costs.
• 68% knew their patients could get pulmonary rehabilitation, but only 38% routinely prescribed it — and rural areas may have few programs.

Telemedicine could help with education, appointments and online test results, though some rural residents still lack internet access. The authors call for educating primary care providers, expanding internet access, physical activity and self-management programs, and better access to pulmonary rehabilitation and oxygen therapy.

How it was measured

Prevalence came from the 2015 Behavioral Risk Factor Surveillance System telephone survey (426,838 adults); hospitalizations from all 335,362 Medicare fee-for-service claims with COPD as the first-listed diagnosis among about 30 million enrollees 65 and older; and deaths from death certificates. Counties were classed by the National Center for Health Statistics' 2013 urban-rural scheme. Self-reported diagnoses can't be verified, survey response rates were low, some hospital claims are readmissions, and the data don't show whether outcomes among people who have COPD differ by where they live.

Sources

Based on Janet B. Croft, Anne G. Wheaton, Yong Liu, et al., "Urban-Rural County and State Differences in Chronic Obstructive Pulmonary Disease — United States, 2015," Morbidity and Mortality Weekly Report, volume 67, Centers for Disease Control and Prevention; a work of the United States government in the public domain.