The Association Between Neighborhood Socioeconomic Disadvantage and Chronic Obstructive Pulmonary Disease

Abstract

Rationale

Individual socioeconomic status has been shown to influence the outcomes of patients with chronic obstructive pulmonary disease (COPD). However, contextual factors may also play a role. The objective of this study is to evaluate the association between neighborhood socioeconomic disadvantage measured by the area deprivation index (ADI) and COPD-related outcomes.

Methods

Residential addresses of SubPopulations and InteRmediate Outcome Measures in COPD Study (SPIROMICS) subjects with COPD (FEV₁/FVC <0.70) at baseline were geocoded and linked to their respective ADI national ranking score at the census block group level. The associations between the ADI and COPD-related outcomes were evaluated by examining the contrast between participants living in the most-disadvantaged (top quintile) to the least-disadvantaged (bottom quintile) neighborhood. Regression models included adjustment for individual-level demographics, socioeconomic variables (personal income, education), exposures (smoking status, packs per year, occupational exposures), clinical characteristics (FEV₁% predicted, body mass index) and neighborhood rural status.

Results

A total of 1800 participants were included in the analysis. Participants residing in the most-disadvantaged neighborhoods had 56% higher rate of COPD exacerbation (P<0.001), 98% higher rate of severe COPD exacerbation (P=0.001), a 1.6 point higher CAT score (P<0.001), 3.1 points higher SGRQ (P<0.001), and 24.6 meters less six-minute walk distance (P=0.008) compared with participants who resided in the least disadvantaged neighborhoods.

Conclusion

Participants with COPD who reside in more-disadvantaged neighborhoods had worse COPD outcomes compared to those residing in less-disadvantaged neighborhoods. Neighborhood effects were independent of individual-level socioeconomic factors, suggesting that contextual factors could be used to inform intervention strategies targeting high-risk persons with COPD.

Keywords:

• health disparities
• COPD
• area deprivation index

Acknowledgments

The authors thank the SPIROMICS participants and participating physicians, investigators and staff for making this research possible. More information about the study and how to access SPIROMICS data is at www.spiromics.org. We would like to acknowledge the following current and former investigators of the SPIROMICS sites and reading centers: Neil E Alexis, MD; Wayne H Anderson, PhD; Mehrdad Arjomandi, MD; Igor Barjaktarevic, MD, PhD; R Graham Barr, MD, DrPH; Lori A Bateman, MSc; Surya P Bhatt, MD; Eugene R Bleecker, MD; Richard C Boucher, MD; Russell P Bowler, MD, PhD; Stephanie A Christenson, MD; Alejandro P Comellas, MD; Christopher B Cooper, MD, PhD; David J Couper, PhD; Gerard J Criner, MD; Ronald G Crystal, MD; Jeffrey L Curtis, MD; Claire M Doerschuk, MD; Mark T Dransfield, MD; Brad Drummond, MD; Christine M Freeman, PhD; Craig Galban, PhD; MeiLan K Han, MD, MS; Nadia N Hansel, MD, MPH; Annette T Hastie, PhD; Eric A Hoffman, PhD; Yvonne Huang, MD; Robert J Kaner, MD; Richard E Kanner, MD; Eric C Kleerup, MD; Jerry A Krishnan, MD, PhD; Lisa M LaVange, PhD; Stephen C Lazarus, MD; Fernando J Martinez, MD, MS; Deborah A Meyers, PhD; Wendy C Moore, MD; John D Newell Jr, MD; Robert Paine, III, MD; Laura Paulin, MD, MHS; Stephen P Peters, MD, PhD; Cheryl Pirozzi, MD; Nirupama Putcha, MD, MHS; Elizabeth C Oelsner, MD, MPH; Wanda K O’Neal, PhD; Victor E Ortega, MD, PhD; Sanjeev Raman, MBBS, MD; Stephen I. Rennard, MD; Donald P Tashkin, MD; J Michael Wells, MD; Robert A Wise, MD; and Prescott G Woodruff, MD, MPH. The project officers from the Lung Division of the National Heart, Lung, and Blood Institute were Lisa Postow, PhD, and Lisa Viviano, BSN; SPIROMICS was supported by contracts from the NIH/NHLBI (HHSN268200900013C, HHSN268200900014C, HHSN268200900015C, HHSN268200900016C, HHSN268200900017C, HHSN268200900018C, HHSN268200900019C, HHSN268200900020C), and a grant from the NIH/NHLBI (U01 HL137880, and supplemented by contributions made through the Foundation for the NIH and the COPD Foundation from AstraZeneca/MedImmune; Bayer; Bellerophon Therapeutics; BoehringerIngelheim Pharmaceuticals, Inc.; Chiesi Farmaceutici S.p.A.; Forest Research Institute, Inc.; GlaxoSmithKline; Grifols Therapeutics, Inc.; Ikaria, Inc.; Novartis Pharmaceuticals Corporation; Nycomed GmbH; ProterixBio; Regeneron Pharmaceuticals, Inc.; Sanofi; Sunovion; Takeda Pharmaceutical Company; and Theravance Biopharma and Mylan. The abstract of this paper was presented at the American Thoracic Society International Conference in May 2019 as a poster presentation and conference talk with interim findings. The poster’s abstract was published in “Abstracts” in the American Journal of Respiratory and Critical Care Medicine (https://www.atsjournals.org/doi/book/10.1164/ajrccm-conference.2019.A26).

Author Contributions

PG, NNH, HW were responsible for the concept, design, data analysis, and initial writing of the manuscript. AK contributed to analyzing the area deprivation index methodology and outcomes. All authors contributed to data analysis, drafting and revising the article, gave final approval of the version to be published, and agree to be accountable for all aspects of the work.

Disclosure

Dr Laura Paulin reports grants from NIEHS, during the conduct of the study. Dr Nirupama Putcha reports grants from NIH, outside the submitted work. Dr Christopher Cooper reports personal fees from GlaxoSmithKline, outside the submitted work. Dr Mark Dransfield reports grants from NIH, during the conduct of the study. Dr R Graham Barr reports grants from NIH, Foundation for the NIH, grants, non-financial support from COPD Foundation, during the conduct of the study. Dr Alejandro Comellas reports grants from NIH, during the conduct of the study; non-financial support from VIDA, outside the submitted work. Dr Meilan Han reports personal fees from GSK, AZ, BI, Merck, and Mylan, non-financial support from Novartis, grants from Sunovion, outside the submitted work. Professor Stephen Peters reports grants from NIH and NHLBI, outside the submitted work. Dr Jerry Krishnan reports grants from NIH and ResMed, during the conduct of the study. Dr Wassim Labaki reports non-financial support from Pulmonx, outside the submitted work. Dr Meredith McCormack reports grants from NIH/NIMHD and Environmental Protection Agency, during the conduct of the study; personal fees from Celgene, Glaxo Smith Kline, and UpToDate, outside the submitted work. Dr Nadia Hansel reports grants, personal fees from AstraZeneca and GSK, grants from Boehringer Ingelheim and COPD Foundation, and NIH; personal fees from Mylan, outside the submitted work. The authors report no other conflicts of interest in this work.