Improving COPD Care in Improving COPD Care in Rural Populations Rural Populations Michael Michael Glasser Glasser , Ph.D. , Ph.D. Associate Dean for Rural Health Professions Associate Dean for Rural Health Professions National Center for Rural Health Professions National Center for Rural Health Professions University of Illinois at Rockford University of Illinois at Rockford Consensus Conference Consensus Conference Setting Effectiveness and Translational Setting Effectiveness and Translational Research Priorities to Improve COPD Care Research Priorities to Improve COPD Care
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Improving COPD Care in Improving COPD Care in Rural PopulationsRural Populations
Michael Michael GlasserGlasser, Ph.D. , Ph.D. Associate Dean for Rural Health Professions Associate Dean for Rural Health Professions National Center for Rural Health Professions National Center for Rural Health Professions
University of Illinois at RockfordUniversity of Illinois at Rockford
Consensus ConferenceConsensus ConferenceSetting Effectiveness and Translational Setting Effectiveness and Translational
Research Priorities to Improve COPD Care Research Priorities to Improve COPD Care
About MeAbout Me
Associate Dean for Rural Health ProfessionsAssociate Dean for Rural Health ProfessionsCoCo--director MPH Program on Rockford campusdirector MPH Program on Rockford campusCoCo--editor editor Education for HealthEducation for HealthMedical SociologistMedical SociologistWhat I am not: expert in COPDWhat I am not: expert in COPDWhat I bring: background in rural health education What I bring: background in rural health education and healthcare delivery and healthcare delivery
National Center for Rural Health National Center for Rural Health Professions (NCRHP)Professions (NCRHP)
Mission: To promote the health of rural : To promote the health of rural communities through partnerships in education, communities through partnerships in education, service, research and policyservice, research and policyCenter ThemesCenter Themes: rural health; : rural health; interprofessionalinterprofessionalcollaboration; health disparities; chronic disease; collaboration; health disparities; chronic disease; international healthinternational healthMajor ProgramsMajor Programs::–– Rural Medical Education (RMED) ProgramRural Medical Education (RMED) Program–– Rural Health Disparities CenterRural Health Disparities Center–– Area Health Education CenterArea Health Education Center
Rural Medical Education (RMED) Rural Medical Education (RMED) ProgramProgram
Purpose is to recruit students from rural areas who Purpose is to recruit students from rural areas who upon residency completion will return to rural upon residency completion will return to rural communities in primary care practicecommunities in primary care practiceAddAdd--on curriculum with students spending 16 on curriculum with students spending 16 weeks in M4 year living in a rural communityweeks in M4 year living in a rural communityResults toResults to--date:date:–– 205 205 matriculantsmatriculants–– Over 80% of graduates selecting primary care and Over 80% of graduates selecting primary care and
practicing in towns of less than 20,000practicing in towns of less than 20,000–– Over 80% staying in rural communities post 5 years of Over 80% staying in rural communities post 5 years of
Rural Health Disparities CenterRural Health Disparities Center
Grew out of NIHGrew out of NIH--funded National Center on funded National Center on Minority Health and Health Disparities Center of Minority Health and Health Disparities Center of Excellence initiative (P20 MD000524)Excellence initiative (P20 MD000524)Purpose is to address the health and health Purpose is to address the health and health disparities of rural and underserved populations disparities of rural and underserved populations through research, education and community through research, education and community outreachoutreachMain emphases toMain emphases to--date: rural health disparities; date: rural health disparities; barriers to care; chronic conditions; Hispanic barriers to care; chronic conditions; Hispanic health; communityhealth; community--based participatory action based participatory action research research
20% of Americans live in rural areas; yet only 9% 20% of Americans live in rural areas; yet only 9% of physicians practice in these areasof physicians practice in these areasNearly 1 in 5 of the uninsured live in rural areas; Nearly 1 in 5 of the uninsured live in rural areas; and rural adults more likely than urban to report and rural adults more likely than urban to report deferred care because of costdeferred care because of costAccess to quality health services is the number Access to quality health services is the number one rural health priorityone rural health priorityResidents of rural areas more likely to:Residents of rural areas more likely to:–– Report fair or poor healthReport fair or poor health–– Have chronic conditions such as diabetesHave chronic conditions such as diabetes–– Die from heart disease Die from heart disease
Rural Mental HealthRural Mental Health
Mental health and mental disorders 4Mental health and mental disorders 4thth most often most often identified rural health priorityidentified rural health priorityMajor issues are access to mental health care and Major issues are access to mental health care and concern for suicide, stress, depression, and concern for suicide, stress, depression, and anxiety disordersanxiety disordersHealthy People 2010 goal is to improve mental Healthy People 2010 goal is to improve mental health and ensure access to appropriate, quality health and ensure access to appropriate, quality mental health servicesmental health servicesCall from Rural Healthy People 2010 to examine Call from Rural Healthy People 2010 to examine the impact of depression as a cothe impact of depression as a co--morbidity for morbidity for other illnesses other illnesses
Depression and COPDDepression and COPD
MengistuMengistu estimates that depression affects about estimates that depression affects about 40% of patients with COPD and is largely 40% of patients with COPD and is largely untreateduntreatedVan Van ManenManen et al. conclude that patients with et al. conclude that patients with severe COPD are at increased risk of developing severe COPD are at increased risk of developing depression and point to the importance of depression and point to the importance of reducing symptoms and improving physical reducing symptoms and improving physical functioning in COPD patientsfunctioning in COPD patients
COPD EpidemiologyCOPD Epidemiology
In the population 25 to 75 years old: In the population 25 to 75 years old: –– Mild COPD Mild COPD 6.9%6.9%–– Moderate 6.6%Moderate 6.6%–– 16 million diagnosed 16 million diagnosed –– Approximately 30 million with the disease Approximately 30 million with the disease
(about 50% not diagnosed)(about 50% not diagnosed)FourthFourth--leading cause of death in US and Europeleading cause of death in US and Europe120,000 deaths in 2000120,000 deaths in 2000Mortality in females has doubled in the last two Mortality in females has doubled in the last two decades decades 85% related to prolonged exposure to tobacco 85% related to prolonged exposure to tobacco smokesmoke
COPD and the Rural Sector COPD and the Rural Sector
Finland studyFinland study: 30 year cumulative incidence of : 30 year cumulative incidence of chronic bronchitis and COPD in middlechronic bronchitis and COPD in middle--aged rural aged rural men (mostly farmers) men (mostly farmers) –––– > 40% of smokers living in rural environment acquired > 40% of smokers living in rural environment acquired
chronic bronchitis during their life; in most cases chronic chronic bronchitis during their life; in most cases chronic bronchitis was persistent and half of these men also bronchitis was persistent and half of these men also acquired COPDacquired COPD
–– 50% of smokers and just under 20% of never50% of smokers and just under 20% of never--smokers smokers with chronic bronchitis later acquired COPDwith chronic bronchitis later acquired COPD
–– Results suggest that smoking reduction was associated Results suggest that smoking reduction was associated with with nonpersistentnonpersistent chronic bronchitis and decreased chronic bronchitis and decreased mortality in smokers mortality in smokers
Rural Sector COPDRural Sector COPDChina studyChina study: : spirometryspirometry--based, crossbased, cross--sectional sectional survey of COPD prevalence in urban and rural survey of COPD prevalence in urban and rural samples, focusing on population 40 years of age samples, focusing on population 40 years of age and older and older –––– Prevalence of 8.2% according to GOLD criteriaPrevalence of 8.2% according to GOLD criteria–– 81.8% of males with COPD were smokers81.8% of males with COPD were smokers–– Higher adjusted OR for COPD in rural areas; Higher adjusted OR for COPD in rural areas;
possibly associated with more biomass possibly associated with more biomass exposure, lower SES, lower healthcare exposure, lower SES, lower healthcare standards, and poorer quality of cigarettesstandards, and poorer quality of cigarettes
–– Good international comparison and discussion Good international comparison and discussion of prevalence rates of prevalence rates
Management Goals for COPDManagement Goals for COPD
Assess and monitor the diseaseAssess and monitor the diseaseReduce risk factors for exacerbationReduce risk factors for exacerbationManage stable COPDManage stable COPDManage COPD exacerbationsManage COPD exacerbations
Key Informant Feedback on COPDKey Informant Feedback on COPD
4 responses: 3 family physicians and 1 fourth4 responses: 3 family physicians and 1 fourth--year year medical student going into family medicine and medical student going into family medicine and having completed 16having completed 16--week rural week rural preceptorshippreceptorshipAll from IllinoisAll from IllinoisResponses to questions sent via eResponses to questions sent via e--mail on issues mail on issues in COPD diagnosis and managementin COPD diagnosis and management
Informant Feedback (1)Informant Feedback (1)Able to accurately and effectively diagnose COPD?Able to accurately and effectively diagnose COPD?–– Yes; Yes; ‘‘No problem, typically only need a history and No problem, typically only need a history and
pulmonary function test.pulmonary function test.’’Able to use pulmonary rehabilitation in your practice?Able to use pulmonary rehabilitation in your practice?–– Generally no; but Generally no; but ‘‘My sense is that pulmonary rehab is My sense is that pulmonary rehab is
principally encouragement for folks to get exercising. As principally encouragement for folks to get exercising. As a primary care doc, I can encourage and support my a primary care doc, I can encourage and support my patients to increase exercise, help them problempatients to increase exercise, help them problem--solve solve to think through their best exercise options. I would not to think through their best exercise options. I would not feel particularly hampered not having a pulmonary feel particularly hampered not having a pulmonary rehab program available. But I would check into the rehab program available. But I would check into the evidence for added benefit of a specific pulmonary evidence for added benefit of a specific pulmonary rehab program.rehab program.’’
Informant Feedback (2)Informant Feedback (2)
Major barriers to using pulmonary rehabilitation? Major barriers to using pulmonary rehabilitation? –– ‘‘Getting patients to commit and getting them to continue Getting patients to commit and getting them to continue
after the formal component is over.after the formal component is over.’’–– ‘‘Patient compliance.Patient compliance.’’–– ‘‘Nearest facility is 20 miles away and most patients will Nearest facility is 20 miles away and most patients will
not travel that far.not travel that far.’’–– ‘‘Time constraints.Time constraints.’’–– ‘‘Costs.Costs.’’–– ‘‘Availability of multidisciplinary team/personnel.Availability of multidisciplinary team/personnel.’’
Informant Feedback (3)Informant Feedback (3)
Strategies you use with COPD patients for risk Strategies you use with COPD patients for risk factor reduction?factor reduction?–– ‘‘SpirometrySpirometry..’’–– ‘‘Motivational interviewing.Motivational interviewing.’’–– ‘‘Only effective strategies I know are smoking Only effective strategies I know are smoking
cessation and avoidance of environmental dust cessation and avoidance of environmental dust and solvents.and solvents.’’
Additional strategies for risk factor reduction?Additional strategies for risk factor reduction?–– ‘‘Increased efforts to decrease smoke exposure Increased efforts to decrease smoke exposure
and continued efforts to improve quality of air and continued efforts to improve quality of air we breathe.we breathe.’’
–– ‘‘Make cigarettes $25 a pack.Make cigarettes $25 a pack.’’
Informant Feedback (5)Informant Feedback (5)What effective strategies do you use for smoking What effective strategies do you use for smoking cessation in COPD patients? cessation in COPD patients? –– ‘‘Combining motivational and pharmaceutical Combining motivational and pharmaceutical
approaches.approaches.’’–– ‘‘Never, never, never giving up on possibility that Never, never, never giving up on possibility that
someone will quit smoking.someone will quit smoking.’’–– ‘‘Use of Use of ChantixChantix to aid in smoking cessation has to aid in smoking cessation has
been the most practical help.been the most practical help.’’–– ‘‘Increased cost of smoking has motivated Increased cost of smoking has motivated
patients to quit.patients to quit.’’–– ‘‘Repetitive intervention (5As).Repetitive intervention (5As).’’–– ‘‘Nicotine replacement/pharmacotherapy.Nicotine replacement/pharmacotherapy.’’
Informant Feedback (6.1)Informant Feedback (6.1)
Major barriers to smoking cessation in your COPD Major barriers to smoking cessation in your COPD patients?patients?–– ‘‘Personal sense of hopelessness/failure.Personal sense of hopelessness/failure.’’–– ‘‘Need for better Need for better neuroneuro--psychopsycho--pharmaceuticals pharmaceuticals
(nicotine is perhaps the most mind(nicotine is perhaps the most mind--altering drug altering drug out there).out there).’’
–– ‘‘Behavioral challenges that remain after treating Behavioral challenges that remain after treating with medication with medication –– they are still tempted to they are still tempted to smoke in certain settings to help relieve their smoke in certain settings to help relieve their stress.stress.’’
Informant Feedback (6.2)Informant Feedback (6.2)
Major barriers to smoking cessation in your COPD Major barriers to smoking cessation in your COPD patients?patients?–– ‘‘Lack of coverage/cost of pharmacotherapy.Lack of coverage/cost of pharmacotherapy.’’–– ‘‘Patient fear of weight gain/interruption of social Patient fear of weight gain/interruption of social
activities/loss of coping mechanism.activities/loss of coping mechanism.’’
Informant Feedback (7)Informant Feedback (7)
To what extent is work in the agricultural sector a To what extent is work in the agricultural sector a factor in COPD?factor in COPD?–– ‘‘Agricultural work is decreasing as a risk factor as Agricultural work is decreasing as a risk factor as
farming practices become safer; most tractors now have farming practices become safer; most tractors now have enclosed cabs making spring work safer from dust enclosed cabs making spring work safer from dust exposure.exposure.’’
–– ‘‘Fall exposure to bean dust is a seasonal factor; a wood Fall exposure to bean dust is a seasonal factor; a wood working hobby is a risk factor.working hobby is a risk factor.’’
Approximate percentage of your COPD patients Approximate percentage of your COPD patients who have depression? Three responses:who have depression? Three responses:–– 25%25%–– 30%30%–– 85%85%
Informant Feedback (9.1)Informant Feedback (9.1)
What could be improvedWhat could be improved in your care of COPD in your care of COPD patients?patients?–– ‘‘Effective, committee team approach in the office.Effective, committee team approach in the office.’’–– ‘‘Group visits Group visits mightmight work within this population.work within this population.’’–– ‘‘Systematic screening of smokers for evidence of early Systematic screening of smokers for evidence of early
COPD might persuade some to quit.COPD might persuade some to quit.’’–– ‘‘Having time and resources to do screening and patient Having time and resources to do screening and patient
recall work is the major barrier; I have a recall work is the major barrier; I have a spirometerspirometer that that hooks up directly to my EMR hooks up directly to my EMR –– but I use it sporadically.but I use it sporadically.’’
Informant Feedback (9.2)Informant Feedback (9.2)
What could be improvedWhat could be improved in your care of COPD in your care of COPD patients?patients?–– ‘‘In the rural health care clinic setting, reimbursement is In the rural health care clinic setting, reimbursement is
such that there are no extra resources to do a screening such that there are no extra resources to do a screening program separate from an office visit. program separate from an office visit. SpirometerSpirometer tests tests take staff from duties that actually get paid for.take staff from duties that actually get paid for.’’
–– ‘‘More frequent assessment.More frequent assessment.’’–– ‘‘Increased success in smoking cessation/counseling.Increased success in smoking cessation/counseling.’’
Research ConsiderationsResearch Considerations
At the At the ‘‘externalexternal’’ level, access to quality care is still level, access to quality care is still an issue and cost remains a barrieran issue and cost remains a barrierAt the At the ‘‘internalinternal’’ level, whether rural or urban, a key level, whether rural or urban, a key concern is patient buyconcern is patient buy--in and ongoing commitmentin and ongoing commitmentAt the At the ‘‘mental or psychologicalmental or psychological’’ level, it is level, it is important to understand and address the role of important to understand and address the role of stress and depression in a personstress and depression in a person’’s lifes lifeAt the At the ‘‘practicepractice’’ level, the use of interdisciplinary level, the use of interdisciplinary teams needs to be studiedteams needs to be studiedOtherOther……
Selected ReferencesSelected References
GammGamm L, Stone S, Pittman S. Mental health and mental disorders L, Stone S, Pittman S. Mental health and mental disorders –– A A rural challenge. rural challenge. Rural Healthy People 2010Rural Healthy People 2010. 2003. College Station, TX: . 2003. College Station, TX: The Texas A&M University System Health Sciences Center.The Texas A&M University System Health Sciences Center.GlasserGlasser M, M, HunsakerHunsaker M, Sweet K, M, Sweet K, MacDowellMacDowell M, M, MeurerMeurer M. A M. A comprehensive medical education program response to rural primarcomprehensive medical education program response to rural primary y care needs. care needs. Academic MedicineAcademic Medicine 2008 83:9522008 83:952--961. 961. MengistuMengistu A. Depression and COPD in older people: A review and A. Depression and COPD in older people: A review and discussion. discussion. British Journal of Community NursingBritish Journal of Community Nursing 2005; 10:422005; 10:42--46.46.PelkonenPelkonen M, M, NotkolaNotkola IL, IL, NissinenNissinen A, A, TukiainenTukiainen H, H, KoskelaKoskela H. ThirtyH. Thirty--year cumulative incidence of chronic bronchitis and COPD in relayear cumulative incidence of chronic bronchitis and COPD in relation to tion to 3030--year pulmonary function and 40year pulmonary function and 40--year mortality. year mortality. ChestChest2006:130:11292006:130:1129--1137.1137.van van ManenManen JG, JG, BindelsBindels PJE, PJE, DekkerDekker FW, FW, IjzermansIjzermans CJ, van CJ, van derder Zee et Zee et al. Risk of depression in patients with chronic obstructive pulmal. Risk of depression in patients with chronic obstructive pulmonary onary disease and it determinants. disease and it determinants. ThoraxThorax 2002; 57:4122002; 57:412--416.416.ZhongZhong N, Wang C, N, Wang C, WanzhenWanzhen Y, Chen P, Kang J, et al. Prevalence of Y, Chen P, Kang J, et al. Prevalence of chronic pulmonary disease in China. chronic pulmonary disease in China. American Journal of Respiratory American Journal of Respiratory Critical Care MedicineCritical Care Medicine 2007 176:7532007 176:753--760. 760.
