azph12305

2015 Online Australian and New Zealand Journal of Public Health 1
© 2015 Public Health Association of Australia
S
ocioeconomic status (SES) is a key
determinant of health outcomes,
particularly for chronic diseases.1-8
In
a systematic review of chronic obstructive
pulmonary disease (COPD) and SES, Gershon
et al.1
found that individuals at the lowest
socioeconomic strata were at least twice
as likely to have poor outcomes as those of
the highest, regardless of gender, age and
population. The differences are associated
with multiple factors, including variations in
access to health care,6,9
diagnostic practices,6
cigarette smoking,10-11
occupational and
environmental exposures,2,12-18
childhood
respiratory infections17,19-20
and pre-term
births.21
In an analysis of data from the 2011
Behavioural Risk Factor Surveillance System
in the US,5
respondents who did not have
a high school diploma reported a higher
prevalence of COPD (9.5%) than those with a
high school diploma (6.8%) or some college
(4.6%). Reported COPD prevalence decreased
with increasing household income, more
current smokers reported having COPD
(13%) than former smokers (6.8%) or never
smokers (2.8%), and respondents with a
history of asthma were significantly more
likely to have been diagnosed with COPD
(20.3%) than those without asthma (3.8%).
In the US, occupations that had the highest
risk for COPD (smokers and never smokers
combined) were freight, stock and material
handlers, the armed forces, vehicle mechanics
and records processing and distribution
clerks.22
Among never smokers, the risk
was also high for machine operators and
construction trades and labourers. In New
Zealand, Fiswick et al.23
found an association
between airflow obstruction and working as
cleaners, bakers, spray painters, laboratory
technicians, and plastics and rubber workers
and in construction and mining. Chronic
bronchitis was reported more often in food
processors, chemical processors and spray
painters and in construction and mining.
COPD often results in hospitalisation, with
systemic manifestations and physical co-
morbidities including depression,24
chest
infections, coronary artery disease and right
heart failure.25
Mental and physical health
co-morbidities in COPD contribute to adverse
health outcomes, such as reduced adherence
to management plans, slower recovery
from exacerbations, increased health care
utilisation and higher mortality rates.25
In 2010–11, Australia’s rate of COPD was 317
hospital separations per 100,000 population
(aged 15 years and over), more than 56%
higher than the Organisation for Economic
Cooperation and Development (OECD)
average.26
During 2007–08 and 2011–12,
the average COPD separation rates did not
change substantially in Australia, but the
OECD average fell from 223 in 2006 to 203 in
2011.9
In the US, COPD was responsible for
8 million physician office visits, 1.5 million
Chronic obstructive pulmonary disease
hospitalisations and mortality inVictoria:
analysis of variations by socioeconomic status
Timothy Ore,1
Paul Ireland1
1. Department of Health, Commission for Hospital Improvement, Victoria
Correspondence to: Dr Timothy Ore, Department of Health, Commission for Hospital Improvement, Level 20, 50 Lonsdale Street, Melbourne, Victoria 3000;
e-mail: timothy.ore@health.vic.gov.au
Submitted: June 2014; Revision requested: August 2014; Accepted: August 2014
The authors have stated they have no conflict of interest.
Aust NZ J Public Health. 2015; Online; doi: 10.1111/1753-6405.12305
Abstract
Objective: This paper analysed chronic obstructive pulmonary disease (COPD) hospitalisations,
unplanned readmissions and deaths in Victoria to identify associations with socioeconomic
status (SES).
Methods: The data was taken from the Victorian Admitted Episodes Dataset, the Victorian
Health Information Surveillance System, the Victorian Burden of Disease Study and the
Australian Bureau of Statistics’Index of Relative Socioeconomic Disadvantage.
Results: COPD separations have a greater variation by SES than all separations. The average
age-standardised separation rate (10.43) for the top percentile Local Government Areas (LGA)
was 5.8 times that of the bottom percentile LGAs (1.80). The top percentile group was the
lowest SES group (effect size = 0.93). There were significant negative correlations between the
age-standardised COPD separation rates and SES across LGAs (r = -0.60) and Regions (r = -0.89).
Analysis of readmissions (r = -0.49), mortality data (r = -0.51) and the burden of disease data
(r = -0.39) also showed significant inverse associations between COPD and SES.
Conclusions and implications: Victorians living in the most disadvantaged areas have a greater
burden from COPD, highlighting a need to prioritise public health services interventions to
improve outcomes.
Key words: coefficient of variation, effect size, socioeconomic gradient, hospital readmissions,
burden of chronic disease

2 Australian and New Zealand Journal of Public Health 2015 Online
Ore and Ireland
emergency department visits and 727,000
hospitalisations (13% of all hospitalisations) in
2000.27
COPD is second only to coronary heart
disease as a reason for payment of Social
Security disability benefits in the US.27
This paper analysed COPD hospitalisation,
unplanned readmission and death data
across all 79 Local Government Areas (LGAs)
in Victoria in 2011–12 to identify the direction
and magnitude of associations between SES
and COPD. Prevalence data reported in the
2001 Victorian Burden of Disease survey was
also examined with a similar objective. This
study, the first to specifically examine SES and
COPD hospitalisations and readmissions at a
detailed level in Victoria, points to a need for
further actions on prevention, early diagnosis
and effective treatment strategies to manage
the burden from COPD. An understanding of
the relationship is important for designing
clinical and policy strategies to improve the
health of people with COPD.1
Methods
Data
The numerator data (separations and
30-day unplanned readmissions) was from
the Victorian Admitted Episodes Dataset,
public and private hospitals, for 2011–12,
for patients with a COPD diagnosis. COPD is
a generic term for emphysema and chronic
bronchitis. Death data (avoidable mortality)
for 2002–06 was taken from the Victorian
Health Information Surveillance System,
containing untimely and unnecessary deaths
from diseases for which effective public
health and medical intervention are available.
The denominator data (persons aged 25 years
and over) was from the Estimated Resident
Population (ERP) by the Australian Bureau of
Statistics (ABS). The ERP is the official estimate
of the Australian population, based on usual
place of residence. The data is provided at
several levels, including at the LGA.
Data was also taken from the Victorian Burden
of Disease Study: Mortality and Morbidity
in 2001.28
This provides a comprehensive
assessment of the health status of Victorians,
including chronic respiratory disease.
For socioeconomic status, the ABS Index of
Relative Socioeconomic Disadvantage (IRSED)
was used. The index is derived from attributes
including low income, low educational
attainment, high unemployment and jobs in
relatively unskilled occupations. The higher
an area’s IRSED, the less disadvantaged that
area is compared with other areas. A high
IRSED indicates that an area has few families
of low income and few people with little
training and in unskilled occupations.
Statistical analysis
Rates were calculated as the number of
COPD hospital separations (for patients over
25 years of age) divided by the estimated
resident population for the corresponding
age group, multiplied by 1,000. Readmission
rates were per 10,000 population and death
rates were per 100,000 population. Patients
younger than 25 years of age represented
less than 1% of the separations. The data was
analysed at the LGA level. The rates were age-
standardised using the direct method, with
Victoria’s 2012 population as the reference.
Statistical analyses were conducted using
SPSS, version 20. The coefficient of variation
(CV) was calculated for COPD separation
and mortality rates, and compared with the
distribution of rates for all separations and
deaths by LGA. CV is computed by dividing
the standard deviation of the data set by
its mean. The distribution of all separation
and death rates by LGA is a useful data
set for comparison to assess the relative
degree of variability between conditions.
As noted by Refshauge and Kalisch,6
when
a condition is common it is more likely to
have a wide distribution of rates. Therefore,
when comparing the variation in rates for
conditions that differ in prevalence, it is
desirable to adjust for this effect.
Results
Profile
There were 15,263 separations (including
4,082 with catastrophic complications or
comorbidities) from 1 July 2011 to 30 June
2012 in Victoria (Table 1). The average length
of stay of was 5.98 days. Patients younger
than 25 years accounted for 0.4% (n=62)
of the separations. The rates increased
significantly (p<0.001) with age (Figure 1).
Hospital separations
Men had a significantly higher average COPD
separation rate per 1,000 population (5.68,
95%CI 4.95–6.41) than women (4.59, 95%CI
4.11–5.06).
The coefficient of variation was 0.49 for COPD
separations and 0.17 for all separations. This
shows that COPD separations have a far
greater variation by LGA than all separations.
Table1:Demographicprofile.
Profile Number Percentage
Gender
Male
Female
8,037
7,226
52.66
47.34
Age
<25
25–29
30–34
35–39
40–44
45–49
50–54
55 -59
60-64
65-69
70-74
75-79
80-84
85 +
62
9
16
54
200
282
444
873
1,279
1,964
2,367
2,583
2,630
2,500
0.41
0.06
0.10
0.35
1.31
1.85
2.91
5.72
8.38
12.87
15.51
16.92
17.23
16.38
Length of StayType
Multiday stay
Overnight stay
Same-day stay
12,280
1,564
1,419
80.46
10.25
9.30
Length of Stay (Days)
1
2
3
4
5
6
7
8
9
10
>10
2,983
1,549
1,727
1,609
1,435
1,164
1,002
704
598
432
2,060
19.54
10.15
11.31
10.54
9.40
7.63
6.56
4.61
3.92
2.83
13.50
HospitalType
Private
Public
2,376
12,887
15.57
84.43
Therefore, location factors play a more
important role in COPD separations.
The average age-standardised separation
rate for the top percentile LGAs was 5.8
times greater than that for the bottom
percentile LGAs, 10.43 compared with 1.80.
The top percentile group was the lowest
SES group (with the lowest IRSED): Buloke
(14.39), Corangamite (8.89), Hindmarsh (10.3),
Loddon (9.42), Moira (9.13), Strathbogie
(13.17), Swan Hill (9.13) and West Wimmera
(8.98). The bottom percentile group were:
Boroondara (1.89), Melbourne (1.30), Golden
Plains (1.83), Nillumbik (1.27), Stonnington
(2.36),Yarra (2.04) and Surf Coast (1.88).
Differences in the age-standardised
separation rates varied significantly between
Regions (females, t-test=10.7, p<0.01; males,
t-test=10.2, p<0.01; and total, t-test=10.6,

Socioeconomic variations in COPD
p<0.01). Hume Region had the highest age-
standardised separation rate, 6.17 (females,
5.51; males, 6.85), 20% above the average for
all Regions (Table 2). Eastern Metro Region
had the lowest rate, 3.01, 41% below the
average.
There were significant (p<0.01) negative
correlations between age-standardised COPD
separation rates and SES across Victorian LGAs
(females, r = -0.622; males, r = -0.523, total, r
= -0.600). This shows that Victorians living in
socioeconomically disadvantaged areas have
higher hospitalisations for COPD (Figures
2–4). Analysis of the data by the Department
of Health’s Regions (Figure 5) showed even
stronger inverse relationships (females, r =
-0.839; males, r = -0.915; and total, r = -0.894).
Unplanned readmissions
Similar to the separations data, Figures 6
and 7 show that age-standardised COPD
readmissions rates per 10,000 population in
2011–12 were significantly associated with
the IRSED by LGA (r = -0.493, p<0.01) and by
Region (r = -0.732, p<0.05).
Burden of disease
Analysis of the burden of disease data also
showed significant (r = -0.39, p<0.01) inverse
associations between COPD prevalence and
socioeconomic status by LGA (Figures 8 to
10). The correlation was stronger for men (r =
-0.435) than women (r = - 0.244).
The average COPD prevalence in the top
percentile LGAs was (2.8%), double that
for the bottom percentile LGAs (1.3%). The
former group were: Ararat (2.61%), Central
Goldfields (3.29%), East Gippsland (2.68%),
Hindmarsh (3.03%), Latrobe (2.66%), Moira
(2.73%), Northern Grampians (2.61%),
Pyrenees (2.77%) and Strathbogie (2.84%).
The latter category comprised: Melbourne
(1.36%),Yarra (1.42%), Stonnington (1.45%),
Port Phillip (1.22%), Casey (1.39%), Melton
(1.27%), Nillumbik (1.13%) and Wyndham
(1.46%).
Four LGAs were in the bottom percentile in
both the COPD hospital separation rates and
the burden of disease data: Melbourne,Yarra,
Stonnington and Nillumbik. Three LGAs were
in the top percentile in both data: Hindmarsh,
Moira and Strathbogie.
Mortality
The coefficient of variation for the age-
standardised COPD death rates (0.43) was

0
5
10
15
20
25
< 25 25 ‐
29
30 ‐
34
35 ‐
39
40 ‐
44
45 ‐
49
50 ‐
54
55 ‐
59
60 ‐
64
65 ‐
69
70 ‐
74
75 ‐
79
80 ‐
84
85 +
Figure1:Age-SpecificCOPD
HospitalSeparationRatesPer1000
Population.

Figure2:AssociationbetweenCOPDHospital
SeparationRatesandSocioeconomicStatusbyLocal
GovernmentArea.
R2
Linear = 0.360

R2
Linear = 0.386
Figure3:AssociationbetweenFemaleCOPDHospital
GovernmentArea.

Figure4:AssociationbetweenMaleCOPDHospital
GovernmentArea.
R2
Linear = 0.273

R2
Linear = 0.799
BSW=BarwonSouthWest;EM=EasternMetro;GIP=Gippsland;GRP=Grampians;
HUM=Hume;LOD=Loddon;NWM=NorthWestMetro;SM=SouthernMetro
Figure5:AssociationbetweenCOPDHospital
SeparationRatesandSocioeconomicStatusbyRegion.

Figure6:AssociationbetweenCOPDUnplanned
ReadmissionRatesandSocioeconomicStatusby
LocalGovernmentArea.
R2
Linear = 0.243
Figure7:AssociationbetweenCOPDUnplanned
ReadmissionRatesandSocioeconomicStatusby
Region.
R2
Linear = 0.536

higher than that for all causes of death (0.17).
Thus, consistent with the separations data,
location factors play a more important role
in COPD mortality (Figures 11 to 13). The
age-standardised death rates decreased
significantly (p<0.01) with increasing
socioeconomic advantage (r = -0.515), for
males (r = -0.443) and females (r = -0.416).
There is a marked metropolitan-rural
differentiation in COPD death rates
(Figure 14).
Discussion
This paper has demonstrated that there
is a significant socioeconomic gradient in
chronic obstructive pulmonary disease
hospitalisations, readmissions, morbidity
and mortality. Victorians living in the most
disadvantaged areas have a greater burden
from COPD. A higher rate of hospital
separations for a given condition in an area
can reflect several circumstances. These
include: a higher prevalence of the more
severe cases of the condition that require
hospital treatment; a higher prevalence of
comorbidities that increase the likelihood of
hospitalisation; and quality of care available
within the primary healthcare setting.6
The effect size in this study between the
lowest and highest socioeconomic groups,
was large. This was 0.93 for separation rates,
0.80 for readmission rates, 0.91 for mortality
rates and 0.964 for prevalence rates. Effect
size is a measure of the magnitude of
difference between two groups. A value of
0.80 and over is considered large.
The age cut-off of 25 years for the COPD data
(excluding asthma) analysed in this paper
was chosen because that is the age at which
people with optimal lung development reach
their full lung function potential, reflected
Table2:Age-standardisedCOPDHospitalSeparationRatesPer1,000Population,2011-12byregion.
Region Female Male Total Rate-Ratio
(forTotal)
Eastern Metro 2.80 3.23 3.01 0.59
NorthWestern Metro 2.67 3.65 3.15 0.61
Southern Metro 3.78 3.83 3.80 0.74
Grampians 4.56 5.56 5.05 0.98
Barwon SouthWest 5.02 5.17 5.09 0.99
Gippsland 5.25 5.94 5.59 1.09
Loddon Mallee 5.41 6.85 6.12 1.19
Hume 5.51 6.85 6.17 1.20
Total 4.59 5.68 5.13
Note:BarwonSouthWest(Colac-Otway,Corangamite,Glenelg,GreaterGeelong,Moyne,Queenscliff,SouthernGrampians,SurfCoast,andWarrnambool);
EasternMetro(Boroondara,Knox,Manningham,Maroondah,Monash,Whitehorse,andYarraRanges);Gippsland(BassCoast,BawBaw,EastGippsland,
Latrobe,SouthGippslandandWellington);Grampians(Ararat,Ballarat,GoldenPlains,Hepburn,Hindmarsh,Horsham,Moorabool,NorthernGrampians,
Pyrenees,WestWimmeraandYarriambiack);Hume(Alpine,Benalla,GreaterShepparton,Indigo,Mansfield,Mitchell,Moira,Murrindindi,Strathbogie,
Towong,WangarattaandWodonga);LoddonMallee(Buloke,Campaspe,CentralGoldfields,Gunnawarra,GreaterBendigo,Loddon,MacedonRanges,
Mildura,MountAlexanderandSwanHill);NorthandWestMetro(Banyule,Brimbank,Darebin,HobsonsBay,Hume,Maribyrnong,Melbourne,Melton,
MooneeValley,Moreland,Nillumbik,Whittlesea,WyndhamandYarra);SouthernMetro(Bayside,Cardinia,Casey,Frankston,GlenEira,Greater
Dandenong,Kingston,MorningtonPeninsula,PortPhillipandStonnington).

Figure8:AssociationbetweenCOPDPrevalenceand
SocioeconomicStatusbyLocalGovernmentArea.
R2
Linear = 0.154

Figure9:AssociationbetweenFemaleCOPD
PrevalenceandSocioeconomicStatusbyLocal
GovernmentArea.
R2
Linear = 0.059

Figure10:AssociationbetweenMaleCOPDPrevalence
andSocioeconomicStatusbyLocalGovernmentArea.
R2
Linear = 0.190
in forced expiratory volume in 1 second.29
Published estimates of COPD prevalence and
hospitalisations often include people aged
15 years and over.30
A New Zealand study23
of
COPD by occupation covered subjects aged
20 to 44 years.
The present findings are consistent with the
literature.1,3,7,17
Gershon et al.1
found that
individuals of the lowest SES were at least
twice as likely to have poor COPD outcomes
as those of the highest SES. Refshauge and
Kalisch6
have shown that COPD hospital
separation rates are higher for people living
in areas with lower SES compared with those
living in areas with higher SES. The authors’
analysis, limited to people aged 55 years and
over, showed that COPD hospital separation
rates were higher in much of the Northern
Territory and north-west Western Australia.
The proportion of the population that
identified as Indigenous all had significant
associations with the hospitalisation rates
for asthma and COPD by area. In Victoria,
between 1979 and 2001, total avoidable
mortality rates (including from COPD) in the
least disadvantaged quintile were significantly
lower than those in the most disadvantaged
quintile.7
The mortality rates were highest in
remote LGAs and lowest in highly accessible
LGAs. In studies that compared associations
between SES and outcomes across several
diseases, disparity was greater with COPD.31
Bourke3
has shown COPD to be more
prevalent in people of lower socioeconomic
status, and men have higher prevalence. The
rate of COPD hospital separations for people
aged 15 and over in Australia in each year
between 2007–08 and 2011–12 was higher
for males than females.26
This may be because
men are more likely to work in manual
trades, such as mining and welding.3
Workers
exposed to coal, silica and cotton, cadmium
and welding fumes have an increased risk of
COPD.2
Men with COPD who continued to be
Ore and Ireland

exposed to fumes at work have an increased
rate of loss of ventilator function.4
Industry-
based epidemiologic studies14
have shown
that occupational exposure to inorganic and
organic dusts and to chemical agents can
increase the risk of COPD. In addition, general
population-based studies15,16
have identified
associations between COPD and employment
in industrial job categories or specific
occupational exposures. In the US, COPD rates
are inversely proportional to socioeconomic
status. Blue collar workers have much
higher COPD morbidity and mortality rates
compared with white collar workers.13
One in five cases of COPD may be attributable
to occupational exposure.12
Occupations that
expose people to COPD are often filled by
people from lower socioeconomic groups.
Smoking has been reported to be more
common among lower socioeconomic
groups. Self-reported data from a computer
assisted telephone survey32
was analysed for
this paper to assess the impact of smoking.
The survey included smoking status (current
smokers, ex-smokers and non-smokers),
frequency of smoking and smoking in home.
The higher the proportions of non-smokers in
a region, the lower the COPD hospitalisation
rates for the region, in both men and women.
The positive correlation between the
percentage of current smokers and COPD
hospitalisation rates was stronger among
men than women (r = 0.63 compared with
r = 0.25). For ex-smokers, the reverse was
observed (r = 0.72 in women, compared with
r = 0.20 in men).
Tobacco smoking is the most important
explanation for the variations in COPD
outcomes reported in this paper. Smoking is
known as the main risk factor for COPD.13,29,33
Half of older smokers develop COPD and
more than 80% of COPD-related morbidity
is attributed to tobacco smoking.33
About
80% of COPD deaths are caused by
smoking.34
Patients with COPD who smoke
have a particularly high level of nicotine
dependence, and about 30% to 43% of
patients with moderate to severe COPD
continue to smoke.33
Other risk factors have been observed,10
including second-hand smoke, poor housing,
damp living conditions and overcrowding.
Such conditions are related to, and increase,
the frequency and spread of respiratory
infections. This, over time, leads to an
increase in the level of indoor air pollution.
Premature and lower birth weights are
also more common in socioeconomically
disadvantaged populations, and low birth
weight is associated with an increased risk
of developing COPD in later life. About 30%
of people born prematurely smoke as young
adults and the reduction in respiratory
function is markedly greater for them than for
smokers who were born at term.29
The OECD9
has noted that rates of avoidable
hospital admissions serve as measures of
the effectiveness of the primary health
care system. This is because access to
a high performing primary health care
system can, to a significant extent, avoid
acute deterioration in people living with
chronic disease conditions. Under the
Australian National Healthcare Agreement
– Intergovernmental Agreement on Federal
Financial Relations, 28-day readmission is a
key‘progress measure’of hospital care.
COPD has an adverse effect on patients’
health-related quality of life. In 2007–08, 27%
of those aged 55 years and over with COPD
rated their health as‘poor’, compared with
13% of those aged 55 years and over without
the condition.35
There has been virtually no change in the
rates of COPD hospital separations in Victoria
over the past ten years, with the average for
the period 2002–03 to 2006–07 (2.62 per
1,000 population) about the same as the
average for the period 2007–08 to 2011–12
(2.67 per 1,000 population). COPD ranks
second on a list of conditions resulting in
avoidable hospitalisation in Australia.36
The
Global Burden of Disease Study 2010 (by the
Institute for Health Metrics and Evaluation)
ranks COPD the third-highest disease burden
in Australia and ninth-highest worldwide.
COPD is projected to rank fifth in 2020
globally. By 2030, COPD is projected to be the
third leading cause of death globally.37
Given
the present and future burden from COPD,
it is imperative that public health drives
effective prevention and management.25
Smoking cessation is the most critical aspect
of COPD management, and should be the
principal focus of interventions and public
education. Patients with COPD who stop
smoking slow down the progression of
disease.13
The National Healthcare Agreement
has a target of reducing the national smoking

Figure11:AssociationbetweenCOPDDeathRatesand
SocioeconomicStatusbyLocalGovernmentArea.
R2
Linear = 0.265 R2
Linear = 0.173
Figure12:AssociationbetweenFemaleCOPDDeath
RatesandSocioeconomicStatusbyLocalGovernment
Area.

Figure13:AssociationbetweenMaleCOPDDeathRates
andSocioeconomicStatusbyLocalGovernmentArea.
R2
Linear = 0.196
Figure14:AssociationbetweenCOPDDeathRatesand
SocioeconomicStatusbyRegion.
R2
Linear = 0.880

rate to 10% of the population and halving the
Indigenous smoking rate by 2018. Among
Australians aged 14 years and older, daily
smoking declined from 15.1% in 2010 to
12.8% in 2013; the age at which 14–24 year
olds smoked their first full cigarette increased
from 14.2 years in 1995 to 15.9 years in 2013.38
In patients with COPD, abstinence from
smoking results in a sustained 50% reduction
in the rate of lung function decline.39,40
However, about 35% of the subjects in the
Lung Health Study (LHS) achieved abstinence
at one year, and only 22% reported continued
abstinence at five years. The LHS was a
randomised clinical trial conducted in 10
clinical centres in the US and Canada among
5,887 male and female smokers aged 35–60
years with early COPD.
Smoking intervention programs can be
effective. Thabane and the COPD Working
Group33
reviewed nine randomised controlled
trials, with a total of 8,291 participants with
a proven diagnosis of COPD. Compared
with usual care, smoking abstinence
rates were significantly higher in COPD
patients receiving intensive counselling or
a combination of intensive counselling and
nicotine replacement therapy. Abstinence
rates were significantly greater in COPD
patients receiving nicotine replacement
therapy compared with placebo.
Pulmonary rehabilitation is another
intervention that can be implemented
across health services. Using a combination
of exercise and education, pulmonary
rehabilitation programs are designed to
improve COPD patients’quality of life,
increase exercise tolerance and enhance their
independence.13
In a randomised controlled
study41
of 95 patients in seven hospitals with
advanced COPD, compared with the control
group, hospital admissions for general health
fell by 57%, unscheduled physician visits
dropped by 59% and hospitalisations for
acute exacerbations were reduced by 40%.
Golmohammadi et al.42
showed that over one
year, pulmonary rehabilitation was associated
with decreased health service utilisation,
reduced direct costs and improved health
status of people with COPD. Cecins et al.43
demonstrated a 42% reduction in the number
of people admitted to hospital with an
exacerbation of COPD and a 62% reduction
in total bed-days following pulmonary
rehabilitation. As noted by Albertson et
al.44
, pulmonary rehabilitation should be
considered for every COPD patient without
regard to age.
While pulmonary rehabilitation has been
demonstrated to be cost-effective, the uptake
of the program is less than ideal. About 1%
of people with COPD who would benefit
from pulmonary rehabilitation have access to
the programs.45
Attendance is also an issue;
between 8% and 50% of those referred to
pulmonary rehabilitation never attend and
between 10% and 32% of those who start the
program do not complete it.
Public education on COPD is also needed;
COPD is a preventable condition. Better
understanding of the risk factors might
allow clinicians to recommend risk reduction
behaviours in a timely manner and diagnose
the condition early, with the possibility of
reducing morbidity and mortality in affected
groups.13
Dirven et al.46
have examined the
impact of a screening program to diagnose
COPD early in primary care practices in
areas of different socioeconomic status
and whether a patient-driven or provider-
driven approach achieved more diagnoses
of COPD. The program yielded 33% new
COPD diagnoses in low socioeconomic
status groups and 23% in all practices. Many
countries have instituted large-scale efforts to
promote awareness of COPD and encourage
early diagnosis. These include the National
Lung Health Education Program in the US,
the Detection, Interaction and Monitoring
of COPD and Asthma project in The
Netherlands and the Know the Age ofYour
Lung project in Poland.47
Another intervention strategy is integrated
disease management (IDM). Broadly, IDM is
an arrangement where different health care
providers (doctors, physiotherapists and
nurses) co-operate and collaborate to provide
different components of care, including self-
management, medication, exercise training
and education. A Cochrane systematic
review48
of 26 studies with 2,997 people with
COPD in 11 countries has shown that this
approach improved disease-specific quality
of life and exercise capacity and reduced
hospital admissions and hospital days per
person. In COPD patients treated with IDM,
hospitalisation decreased by three days
compared with controls.
Care bundles (including strong case
management, discharge planning and
post-discharge support) have been
advocated by several researchers as a useful
intervention.49-51
Winn et al.50
found that
using a COPD care bundle helped reduce
readmissions with acute exacerbations
of COPD. Matthews et al.51
designed and
piloted a care bundle at the James Paget
University Hospital Foundation in the United
Kingdom. Analysis of the data generated by
the intervention showed that, 12 months
post-implementation, 30-day unplanned
readmission fell from 23.2% to 17.8%.
In the US, hospitals with low readmission
rates incorporate evidence-based practices
into daily protocols, standardise procedures,
use electronic information systems to
gather information, provide feedback and
support clinical decisions, and have regular
communication across care teams and with
patients and their families.52,53
The hospitals
identify and target patients at high risk for
readmission, particularly elderly patients and
patients with complex medical and social
needs. The low-readmission-rate hospitals
provide individualised education, schedule
follow-up appointments with community
physicians, and ensure that patients and their
families receive post-discharge instructions
and understand the instructions. The
hospitals also check in with high-risk patients
after discharge by having nurses call patients
and relay critical information to providers.
Factors that seem to reduce unplanned
readmissions at these hospitals include
strong relationships between hospitals and
local primary care providers and nursing
homes, home health care agencies, close
co-ordination between the hospitals and
palliative care and hospice programs, and
efforts to understand and honour patients’
preferences for end of life care.
Generally, people with COPD tend to
experience insufficient service delivery in
the long term, with care focused on acute
exacerbations rather than regular follow-
up and palliative or supportive care.54
Often, in-hospital management of COPD
exacerbations do not follow standard
guidelines, with high variability across
different hospitals in areas such as referral to
pulmonary rehabilitation, patient education
and smoking cessation.55
To identify key
quality indicators for the management of
COPD exacerbations, Lodewijckx et al.56
conducted a Delphi study of 35 experts
from 15 countries, including 19 medical
doctors, 8 nurses and 8 physiotherapists. The
highest consensus was reported for oxygen
therapy, patient education, pulmonary
rehabilitation, understanding therapy and
self-management. To encourage continuous
quality improvement, these indicators should
be embedded in daily clinical practice.
Ore and Ireland

Conclusions and implications
This study presents evidence for policy
makers to prioritise public health and health
services interventions, targeting population
groups and specific disease conditions to
reduce health inequalities and associated
costs. The potential for reducing the burden
from COPD depends on prevention, early
diagnosis and access to treatment options.
Individuals with COPD require cohesive
service delivery to meet their needs and
manage acute exacerbations.
References
1. Gershon A, Dolmage TE, Stephenson A, Jackson
B. Chronic obstructive pulmonary disease and
socioeconomic status: a systematic review. IntJChron
ObstructPulmonDis. 2012;9:216-26.
2. Burge PS. Occupation and chronic obstructive
pulmonary disease (COPD). Eur Respir J. 1994;7(6):
1032-4.
3. BourkeSJ.RespiratoryMedicine.Oxford(UK):Blackwell
Publishing; 2003.
4. HarberP,TashkinDP,SimmonsM,CrawfordL,HinizdoE,
ConnettJ.Effectofoccupationalexposuresondecline
oflungfunctioninearlychronicobstructivepulmonary
disease. Am J Respir Crit Care Med. 2007;176(10):
994-1000.
5. Centres for Disease Control and Prevention. Chronic
obstructive pulmonary disease among adults –
United States 2011. MMWR Morb Mortal Wkly Rep.
2012;61(46):938-43.
6. Refshauge A, Kalisch D. Geographic Distribution of
Asthma and Chronic Obstructive Pulmonary Disease
Hospitalisations in Australia 2007-08 to 2009-10.
Canberra (AUST): Australian Institute of Health and
Welfare; 2013.
7. Piers LS, Carson NJ, Brown K. Avoidable mortality in
Victoria between 1979 and 2001. Aust N Z J Public
Health. 2007;31(1):5-12.
8. Chondur R, Li SQ, Guthridge S, Lawton P. Does
relative remoteness affect chronic disease outcomes?
Geographic variation in chronic disease mortality
in Australia, 2002-2006. Aust N Z J Public Health.
2014;38(2):117-21.
9. Organisation for Economic Cooperation and
Development. Health at a Glance: OECD Indicators.
Paris (FRA): OECD; 2013.
10. Krieger J, Higgins DL. Housing and health: Time
again for public health action. Am J Public Health.
2002;92(5):758-68.
11. Thun MJ, Brian DC, et al. 50-year trends in smoking-
related mortality in the United States. N Eng J Med.
2013;368:351-64.
12. Trupin L, Earnet G, San Pedro M, Balmes JR, et al. The
occupationalburdenofchronicobstructivepulmonary
disease. EurRespirJ. 2003;22:462-9.
13. Ferrara A. Chronic obstructive pulmonary disease.
RadiolTechnol. 2011;82(3):245-63.
14. OxmanAD,MuirDCF,ShannonHS,etal.Occupational
dust exposure and chronic obstructive pulmonary
disease: A systematic review of the evidence. Am Rev
RespirDis. 1993;148:38-48.
15. BakkeP,BasteV,HanoaR,etal.Prevalenceofobstructive
pulmonary disease in a general population: Relation
to occupational tile and exposure to some airborne
agents. Thorax. 1991;46:863-70.
16. Tuchsen F, Hannerz H. Social and occupational
differences in chronic obstructive lung disease in
Denmark 1981-1993. AmJIndMed. 2000;37:300-6.
17. PrescottE,VestboJ.Socioeconomicstatusandchronic
obstructive pulmonary disease. Thorax. 1999;54(8):
737-41.
18. Simpson R, Williams G, Petroeschevsky A, et al.
The short-term effects of air pollution on hospital
admissions in four Australian cities. Aust N Z J Public
Health. 2005;29:213-21.
19. Hegewald MJ, Crapo RO. Socioeconomic status and
lung function. Chest. 2007;132(5):1608-14.
20. McKenzie DK, Frith PA, Burdon JGW, Town GI. The
COPDX plan: Australian and New Zealand Guidelines
forthemanagementofchronicobstructivepulmonary
disease. MedJAust. 2003;178 Suppl 6:1-40.
21. Doyle LW, Olinsky A, Faber B, Callanan C. Adverse
effects of smoking on respiratory function in young
adultsbornweighinglessthan1000grams.Paediatrics.
2003;112:565-9.
22. HnizdoE,SullivanPA,BangKM,WagnerG.Association
between chronic obstructive pulmonary disease and
employment by industry and occupation in the US
population: A study of data from the Third National
Health and Nutrition Examination Survey. Am J
Epidemiol. 2002;156(80):738-46.
23. Fishwick D, Bradshaw LM, D’Souza W, et al. Chronic
bronchitis,shortnessofbreathandairflowobstruction
by occupation in New Zealand. Am J Respir Crit Care
Med. 1997;156:1440-6.
24. AgustiAG,NogueraA,SauledaJ,SalaE,PonsJ,Busquets
X. Systemic effects of chronic obstructive pulmonary
disease. EurRespirJ. 2003;21:347-60.
25. Frith PA, Cafarella PA, Duffy JM. Chronic obstructive
pulmonary disease (COPD) is a major personal and
public health burden in Australia. Aust N Z J Public
Health. 2008;32(2):139-41.
26. AustralianInstituteofHealthandWelfare.OECDHealth-
care Quality Indicators for Australia 2011-12. Canberra
(Aust): AIHW; 2014.
27. Casaburi R, ZuWallack. Pulmonary rehabilitation
for management of chronic obstructive pulmonary
disease. NEnglJMed. 2009;360:1329-35.
28. Department of Human Services. Victorian Burden
of Disease Study: Mortality and Morbidity in 2001.
Melbourne(AUST):StateGovernmentofVictoria;2005.
29. Baraldi E, Filippone M. Chronic lung disease after
premature birth. NEnglJMed. 2007;357(19):1946-55.
30. AmericanLungAssociation.AmericanLungAssociation
Lung Disease Data 2008. Chicago (IL):The Association;
2008.
31. Lantz PM, House JS, Lepkowski JM, Williams DR,
Mero RP, Chen J. Socioeconomic factors, health
behaviours, and mortality: Results from a nationally
representative prospective study of US adults. JAMA.
1998;279(21):1703-8.
32. Department of Health. Victorian Population Health
Survey2010:SelectedFindings.Melbourne(AUST):State
Government ofVictoria; 2012.
33. Thabane and the COPD Working Group. Smoking
cessation for patients with chronic obstructive
pulmonary disease. Ont Health Technol Assess Ser.
2012;12(4):1-50.
34. United States Department of Health and Human
Services.TheHealthConsequencesofSmoking–50Years
ofProgress:AReportoftheSurgeonGeneral.Washington
(DC): USDHHS; 2014.
35. AustralianBureauofStatistics.4362.0.-NationalHealth
Survey:SummaryResults. Canberra (AUST): ABS; 2009.
36. GloverJ,PageA,AmbroseS,HetzelD.AtlasofAvoidable
Hospitalisations in Australia: Ambulatory Care-sensitive
Conditions. Canberra (AUST): Australian Institute of
Health andWelfare; 2007.
37. World Health Organisation. Burden of Chronic
Obstructive Pulmonary Disease (COPD) [Internet].
Geneva (CHE): WHO; 2013 [cited 2014 May 28].
Available from: www.who.int/respiratory/copd/
burden/en/index.html
38. Australian Institute of Health and Welfare. Tobacco
Smoking:NationalDrugStrategyHouseholdSurvey2013.
Canberra (AUST): AIHW; 2013.
39. Anthonisen NR, Connett JE, Murray RP. Smoking and
lung function of Lung Health Study participants after
11 years. AmJRespirCare. 2002;166:675-9.
40. Sutherland ER, Cherniack RM. Management of
chronic obstructive pulmonary disease. N Engl J Med.
2004;350(26):2689-97.
41. BourbeauJ,JulienM,MaltaisF,Rouleau M, Beaupre A,
etal.Reductionsinhospitalutilisationinpatientswith
chronicobstructivepulmonarydisease.ArchInternMed.
2003;163(5):585-91.
42. GolmohammadiK,JacobsP,SinD.Economicevaluation
of a community-based pulmonary rehabilitation
program for chronic obstructive pulmonary disease.
Lung. 2004;182(1):187-96.
43. Cecins N, Geelhoed E, Jenkins S. Reduction in
hospitalisation following pulmonary rehabilitation in
patientswithCOPD.AustHealthRev.2008;32(3):415-22.
44. Albertson TE, Schivo M, Zeki AA, Louie S, et al. The
pharmacologicalapproachtotheelderlyCOPDpatient.
DrugsAging. 2013;30:479-502.
45. Brooke M. COPD and its management in Australia. J
AustralasRehabiNursAssoc.2013;16(2):8-12.
46. Dirven JA, Tange HJ, Muris JW, van Haaren KM, et al.
Early detection of COPD in general practice: patient
or practice managed? A randomised controlled
trial of two strategies in different socio-economic
environments. PrimCareRespirJ. 2013;22(3):331-7.
47. Price D, Freedman D, Cleland J, Kaplan A, et al. Earlier
diagnosis and earlier treatment of COPD in primary
care. PrimCareRespirJ. 2011;20(1):15-22.
48. Kruis AL, Smidt N, Assendelft WJJ, Gussekloo J,
Boland MRS, et al. Integrated disease management
interventions for patients with chronic obstructive
pulmonary disease (Cochrane Review). In: The
CochraneDatabaseofSystematicReview;Issue10,2013.
Chichester (UK): JohnWiley; 2013.
49. Hopkins NS, Englebretsen C, Cooley N, Keenie K, et al.
DesigningandimplementingaCOPDdischargecare-
bundle. Thorax. 2012;67:90-2.
50. Winn T, Noone M, Buxton M. How a COPD care
bundle is reducing admissions. Health Serv J. 2011;
November 22.
51. Matthews H, Tooley C, Nicholls C, et al. Care
bundles reduce readmissions for COPD. Nurs Times.
2013;109(7):18-20.
52. Boutwell A, Hwu S. Effective Interventions to Reduce
Re-hospitalisations: A Survey of the Published Evidence.
Cambridge(MA):InstituteforHealthcareImprovement;
2009. p. 14.
53. Silow-CarrollS,EdwardsJN,LashbrookA,etal.Reducing
Hospital Readmissions: Lessons from Top-performing
Hospitals. New York (NY): The Commonwealth Fund;
2011 April.
54. Gysels M, Higginson I. Self-management for
breathlessness in COPD: The role of pulmonary
rehabilitation. ChronRespirDis. 2009;6:133-40.
55. Lodewijckx C, Sermeus W, Panella M, Deneckere S, et
al. In-hospital management of COPD exacerbations:
A systematic review of the literature with regard to
adherencetointernationalguidelines.JEvalClinPract.
2009;15:1101-10.
56. Lodewijckx C, Sermeus W, Panella M, Deneckere S, et
al. Quality indicators for in-hospital management of
exacerbationofchronicobstructivepulmonarydisease:
Results of an international Delphi study. J Adv Nurs.
2012;69(2):348-62.

azph12305

Recommended

Recommended

More Related Content

What's hot

What's hot (19)

Viewers also liked

Viewers also liked (10)

Similar to azph12305

Similar to azph12305 (20)

azph12305