Defining and targeting health disparities in chronic obstructive pulmonary disease

Figures & data

Table 1 Whitehead’s principal determinants of health disparities and COPD correlates

General determinants of health disparities	Corresponding determinants for COPD
Natural biologic variation	Genetic susceptibilities
Health-damaging behavior of individuals	Smoking tobacco and/or biomass fuel use
Transient health advantage for people who adopt new behaviors first	Educated people making behavioral changes more readily than those with lower levels of education
Health-damaging behavior in which the degree of choice of lifestyles is severely restricted	People being born into and remaining in impoverished and low education settings
Exposure to unhealthy living and working conditions	Exposure to environmental (second-hand) smoke and indoor biomass fuels
Inadequate access to health care	People in lower socioeconomic status and having less health care access
Natural selection leading to the tendency for the sick to move down the social hierarchy	People with advanced COPD become disabled due to disease

Note: Data adapted from Whitehead M. The concepts and principles of equity and health. Health Promotion Int. 1991;6:217–228.¹⁶

Abbreviation: COPD, chronic obstructive pulmonary disease.

Table 2 Relationship between socioeconomic status and respiratory measures

References	Population (description and N)	Socioeconomic status measure(s)	Outcome measure(s)	Main findings
Trinder et al^Citation17	General practices in UK (N=4,237)	Occupation of householder	Respiratory symptoms	Severity of respiratory symptoms worse in people with manual occupation in the presence of tobacco use
Shohami et al^Citation18	Adults in UK attending general medical practices (N=22,675)	Occupation, education level, and area deprivation	Lung function impairment	Occupation, educational level, and living in area of deprivation associated with worse lung function
Welle et al^Citation19	Norwegian general population survey (N=1,275)	Educational level	DLCO	DLCO related to education in men, not women
Schikowski et al^Citation20	Germany (N=1,251, women only)	Education level, occupation, and residence	Lung function, respiratory symptoms, and air particulate matter	Low education more likely to suffer from low FEV1 and were occupationally exposed to particulate matter >10 ppm
Smith et al^Citation21	Chinese population (never smokers) in ten regions (N=307,000)	Household income and education level	Prevalence of AO	AO associated with lower education and income
Kurmi et al^Citation22	Cross-section of adults in ten diverse populations across China (N=500,000 adults)	Household annual income	Prevalence of AO and respiratory symptoms	AO inversely related to annual income
Liu et al^Citation23	Cross-sectional survey in one US state (N=4,300 adults)	Education level	Prevalence of respiratory symptoms	Low educational level associated with higher frequency of respiratory symptoms, including frequent productive cough, dyspnea, and SOB affects ADLs

Abbreviations: ADLs, activities of daily life; AO, airflow obstruction; DLCO, diffusion capacity of the lung for carbon monoxide; FEV₁, forced expiratory volume in 1 second; ppm, parts per million; SOB, shortness of breath.

Table 3 Relationship between socioeconomic status and COPD prevalence

References	Population, description, and N	Socioeconomic status measure(s)	Outcome measure(s)	Main findings
Bakke et al^Citation24	Cross-sectional study of general adult population in Norway (N=1,512)	Occupation	Asthma and COPD prevalence	OR of 3.6 for obstructive lung disease in people with high degree of airborne exposure
Eachus et al^Citation25	Adults from 40 general practices in the UK (N=28,080)	Deprivation score based on residence	Disease prevalence including COPD	Emphysema and chronic bronchitis relative index of 2.72 and 2.27, respectively (values higher than most other conditions)
Chen et al^Citation26	National population survey in Canada (N=7,210)	Income	COPD disease prevalence	For low income persons OR = 3.7 for males and 2.4 for females
Marmot et al^Citation27	Civil servants in London, UK (N=10,308)	Occupation (employment grade)	Chronic bronchitis prevalence	OR for CB for men 1.44 and women 1.21
Montnemery et al^Citation28	Adults in Sweden (N=12,071)	Occupation, social position, and residence location	Prevalence of CBE and respiratory symptoms	CBE more common in unskilled and semiskilled workers, low social position
Lindberg et al^Citation29	Sweden (N=1,165)	Occupation	COPD incidence over 10 years in subjects with respiratory symptoms	Manual workers had an OR = 1.78 vs professionals. Low education level had an OR = 1.73
Ellison-Loschmann et al^Citation30	European Community respiratory health Survey in Europe, Australia, New Zealand, and the US	Educational level and occupational class	Prevalence and incidence of chronic bronchitis	Low educational and occupational levels (prevalence ratio =1.9 and 1.8, respectively)
Halvorsen and Matrinussen^Citation32	Norwegian prescription database of COPD patients (N=62,882)	Educational level and level of unemployment in community	COPD prevalence	Communities with low educational levels and unemployment associated with higher risk of COPD
Karnevisto et al^Citation33	Finland – national population-wide survey (N=6,525)	Education and household income	COPD and asthma prevalence	Education significant risk factor for COPD, whereas low household income was a risk factor for asthma
Lovasi et al^Citation34	Multi-ethnic study of artherosclerosis at multiple sites in the US (N=3,706)	Education, household income, and wealth indicators	Degree of emphysema on computed tomography scan	Higher percent of emphysema in people with lower high school education, annual income, and wealth
Yin et al^Citation35	People’s Republic of China (31 provinces), (N=49,363)	Education and household income	COPD prevalence by self-report	SES predictive of COPD risk independent of smoking and rural vs urban residence
Herrick et al^Citation36	Cross-sectional population study in one US state (N=25,986)	Annual household income and highest level of education	COPD prevalence	COPD prevalence threefold greater between highest and lowest income levels as well as between lowest and highest education levels
Burney et al^Citation60	Multicenter (n=22 countries), international study burden of obstructive lung disease (N=15,355)	Poverty as measured by GNI of countries	COPD prevalence	COPD prevalence fivefold greater between highest and lowest income levels as well as between lowest and highest education levels
Kainu et al^Citation37	Finnish population (N=8,000, COPD N=628)	Occupation	COPD prevalence	Prevalence higher in manual than nonmanual occupations
Golec et al^Citation38	Polish farmers (N=64)	Size of farm	COPD prevalence	Lower SES in COPD patients
Hagstad et al^Citation39	Swedish never-smokers with obstructive lung disease (N=967)	Education level, occupation	Proportion of nonsmokers with COPD who had occupational exposures	OR of COPD related to occupation = 0.72 in college graduates vs those with less than high-school education
Lee et al^Citation40	Korean never smokers with COPD (N=3,473)	Educational level, occupation	COPD prevalence	Low education level and manual labor were risk factors for COPD
Tan et al^Citation41	Canadian cross-sectional study in general adult population (N=5,176)	Educational level	COPD prevalence in ever and never-smokers	Low education level associated with higher prevalence in both never and ever-smokers

Abbreviations: CB, chronic bronchitis; CBE, chronic bronchitis/emphysema; COPD, chronic obstructive pulmonary disease; GNI, gross national income; OR, odds ratio; SES, socioeconomic status.

Table 4 Effect of socioeconomic status on respiratory-related outcomes in chronic obstructive pulmonary disease

References	Population	SES measure	Outcome measure(s)	Main findings
Prescott et al^Citation43	Copenhagen, Denmark general population (N=14,223)	Educational level and household income	Hospitalization for COPD	Higher rates of hospitalization related to income and education levels (independent of smoking history)
Van Rossum et al^Citation42	the Netherlands (N=18,001)	Occupation	Mortality	COPD had highest rate of increased mortality related to occupation compared with other common causes of death
Steenland et al^Citation11	Adults in 27 states in the US, American Cancer Society population (N=1,330,886)	Occupation	All cause and cause-specific mortality	SES gradient most substantial for all specific causes of death
Huisman et al^Citation44	European data from numerous countries (N=1,000,000 deaths)	Education level	Mortality rate in low-educational groups expressed as a proportion of mortality rate in high-educational groups	Low education groups had highest mortality including COPD, cancer, and heart disease
Antonelli-Incazi et al^Citation45	Elderly in Rome, Italy	Income based upon census tract estimate for residence	Hospitalization rate of COPD	Relative risk for females with COPD 3.3 and males 4.3 (higher than other diseases)
Blanc et al^Citation46	US population survey of COPD patients (N=427)	Educational level and annual income	Tiotropium use	Less use of tiotropium with lower SES (OR =0.3)
Reilly et al^Citation47	National survey of 30 provinces in the People’s Republic of China (N=169,871)	Education, residence (urban vs rural)	Mortality	Relative risk of death 2.37 and 2.47 for men and women, respectively. RR for urban vs rural residence 2.14 and 1.79, respectively
Schane et al^Citation48	National cross-sectional US survey (N=18,858 total N=1,736 COPD patients)	Income and education	Risk factors for depression in COPD vs non-COPD	Less than HS education showed OR =1.63 for depression
Wong et al^Citation49	Data from St Paul’s Hospital in Vancouver, BC, Canada	Marital status and need for social work consultation while in hospital	Hospital LOS and readmission rate in AECOPD patients	Marital status and need for social work intervention associated with prolonged LOS and readmission for AECOPD
Lewis et al^Citation10	National Longitudinal Mortality Study in the US (N=184,924)	Marital status, education, health insurance, poverty level, and occupation	Mortality in a general adult population	Education, marital status, and income predictive of mortality, not seen with insured vs uninsured
Arne et al^Citation50	Sweden, survey of 55 municipalities (N=1,475)	Education level, employment status, and social support	Health status and quality of life in COPD vs non-COPD subjects	Lack of social support and low economic status associated with poorer health status in COPD
Calderón-Larrañaga et al^Citation51	UK, national cross-sectional study (N=53,676,021)	Deprivation index	Hospitalizations for COPD	Deprivation and smoking prevalence were variables with highest explanatory power, accounting for 59.3% and 51.4% of the total variance, respectively
Miravitlles et al^Citation52	Spain, nationwide survey (N=4,574)	Education level and occupation	HrQOL in COPD patients	Worse HrQOL in low education level and in unskilled workers
Eisner et al^Citation31	CA, in the US (N=1,202) (insured COPD patients)	Education and income levels	Physical impairment (6-minute walk), pulmonary function, and disease severity including BODE index	Low SES associated with worse physical impairment, pulmonary, function, and disease severity in a COPD population with broad access to health care
Omachi et al^Citation53	CA, in the US, population survey in persons >55 years (N=277)	Health literacy	COPD-related health status and COPD-related ED or hospitalizations using multifactorial analysis adjusted for income and educational levels	Poorer health literacy associated with worse health status, HrQOL, and ED and hospitalizations for COPD
McAllister et al^Citation54	All Scottish residents (UK)	Scottish Index of Multiple Deprivation (measure using multiple domains such as income, housing, access, education)	Hospitalization rates in COPD associated with deprivation index and winter season	SES and winter act synergistically on rate of COPD hospitalizations
Gershon et al^Citation55	ON, Canada	Average household income based on residence	Mortality of COPD	Although overall COPD mortality decreased between 1966 and 2012, differences in COPD mortality between low and high income widened over the study period
Lange et al^Citation56	Copenhagen, Denmark (N=6,590) adults with COPD	Education <8 years, 8–10 years, >10 years with some college or completed college	AECOPD, hospital admissions, mortality	Highest risk of AECOPD, low lung function, and highest respiratory symptoms
Trachtenberg et al^Citation57	Administrative database in Winnipeg, Canada N=34,741 asthma and COPD)	Census-based household income	Hospitalizations for asthma or COPD	Lower SES associated with higher risk of hospitalizations
Sharma et al^Citation58	US Medicare beneficiaries with COPD	Socioeconomic status based on if Medicaid eligible (low SES)	Burn injuries related to oxygen use	Twofold risk of oxygen-related burn injuries in low SES people

Abbreviations: AECOPD, acute exacerbation of COPD; COPD, chronic obstructive pulmonary disease; ED, emergency department; HrQOL, health-related quality of life; LOS, length of stay; OR, odds ratio; RR, relative risk; SES, socioeconomic status.

Figure 1 All-cause mortality rate by socioeconomic status among COPD patients in Canada from 1996/1997 to 2011/2012.

Note: Reprinted with permission of the American Thoracic Society. Copyright © 2016 American Thoracic Society. Gershon AS, Hwee J, Victor JC, Wilton AS, To T. 2014. Trends in socioeconomic status-related differences in mortality among people with chronic obstructive pulmonary disease. Ann Am Thorac Soc. 11:1195–1202. The Annals of the American Thoracic Society is an official journal of the American Thoracic Society.⁵⁵
Abbreviation: COPD, chronic obstructive pulmonary disease.

Figure 2 World Health Organization drug therapy guidelines for managing acute exacerbations of COPD and stable management in resource limited settings.

Note: Reprinted from World Health Organization. Prevention and control of non-communicable diseases: guidelines for primary health care in low-resource settings. Copyright 2012.¹⁴²
Abbreviations: ADRs, adverse drug reactions; AECOPD, acute exacerbation of COPD; COPD, chronic obstructive pulmonary disease; HIV, human immunodeficiency virus; ICS, inhaled corticosteroid; IV, intravenous.

Table 5 Drug costs relative to days of work in low-income people in the US

Measure	Albuterol MDI (200 inhalations)	ICS/LABA inhalera	LAMA inhalera	Albuterol + ICS/LABA + LAMA
Retail drug costsb	$55.00	$340.00	$320.00	$715.00
Days of work required to pay for medication(s) using ~ minimum wagec	0.86 days	5.3 days	5 days	11.2 days

Notes:

a One month supply.

b Approximate retail costs with no subsidies were obtained from www.goodrx.com. Accessed February 1, 2016.¹⁹⁷

c Annual income of $16,640 (based on a minimum wage salary of $8/hour at 40 hours/week).

Abbreviations: MDI, metered dose inhaler; ICS, inhaled corticosteroid; LABA, long-acting beta agonist; LAMA, long-acting antimuscarinic agent.

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