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      Preliminary Estimates of the Prevalence of Selected Underlying Health Conditions Among Patients with Coronavirus Disease 2019 — United States, February 12–March 28, 2020

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          Abstract

          On March 11, 2020, the World Health Organization declared Coronavirus Disease 2019 (COVID-19) a pandemic ( 1 ). As of March 28, 2020, a total of 571,678 confirmed COVID-19 cases and 26,494 deaths have been reported worldwide ( 2 ). Reports from China and Italy suggest that risk factors for severe disease include older age and the presence of at least one of several underlying health conditions ( 3 , 4 ). U.S. older adults, including those aged ≥65 years and particularly those aged ≥85 years, also appear to be at higher risk for severe COVID-19–associated outcomes; however, data describing underlying health conditions among U.S. COVID-19 patients have not yet been reported ( 5 ). As of March 28, 2020, U.S. states and territories have reported 122,653 U.S. COVID-19 cases to CDC, including 7,162 (5.8%) for whom data on underlying health conditions and other known risk factors for severe outcomes from respiratory infections were reported. Among these 7,162 cases, 2,692 (37.6%) patients had one or more underlying health condition or risk factor, and 4,470 (62.4%) had none of these conditions reported. The percentage of COVID-19 patients with at least one underlying health condition or risk factor was higher among those requiring intensive care unit (ICU) admission (358 of 457, 78%) and those requiring hospitalization without ICU admission (732 of 1,037, 71%) than that among those who were not hospitalized (1,388 of 5,143, 27%). The most commonly reported conditions were diabetes mellitus, chronic lung disease, and cardiovascular disease. These preliminary findings suggest that in the United States, persons with underlying health conditions or other recognized risk factors for severe outcomes from respiratory infections appear to be at a higher risk for severe disease from COVID-19 than are persons without these conditions. Data from laboratory-confirmed COVID-19 cases reported to CDC from 50 states, four U.S. territories and affiliated islands, the District of Columbia, and New York City with February 12–March 28, 2020 onset dates were analyzed. Cases among persons repatriated to the United States from Wuhan, China, and the Diamond Princess cruise ship were excluded. For cases with missing onset dates, date of onset was estimated by subtracting 4 days (median interval from symptom onset to specimen collection date among cases with known dates in these data) from the earliest specimen collection. Public health departments reported cases to CDC using a standardized case report form that captures information (yes, no, or unknown) on the following conditions and potential risk factors: chronic lung disease (inclusive of asthma, chronic obstructive pulmonary disease [COPD], and emphysema); diabetes mellitus; cardiovascular disease; chronic renal disease; chronic liver disease; immunocompromised condition; neurologic disorder, neurodevelopmental, or intellectual disability; pregnancy; current smoking status; former smoking status; or other chronic disease ( 6 ). Data reported to CDC are preliminary and can be updated by health departments over time; critical data elements might be missing at the time of initial report; thus, this analysis is descriptive, and no statistical comparisons could be made. The percentages of patients of all ages with underlying health conditions who were not hospitalized, hospitalized without ICU admission, and hospitalized with ICU admission were calculated. Percentages of hospitalizations with and without ICU admission were estimated for persons aged ≥19 years with and without underlying health conditions. This part of the analysis was limited to persons aged ≥19 years because of the small sample size of cases in children with reported underlying health conditions (N = 32). To account for missing data among these preliminary reports, ranges were estimated with a lower bound including cases with both known and unknown status for hospitalization with and without ICU admission as the denominator and an upper bound using only cases with known outcome status as the denominator. Because of small sample size and missing data on underlying health conditions among COVID-19 patients who died, case-fatality rates for persons with and without underlying conditions were not estimated. As of March 28, 2020, a total of 122,653 laboratory-confirmed COVID-19 cases (Figure) and 2,112 deaths were reported to CDC. Case report forms were submitted to CDC for 74,439 (60.7%) cases. Data on presence or absence of underlying health conditions and other recognized risk factors for severe outcomes from respiratory infections (i.e., smoking and pregnancy) were available for 7,162 (5.8%) patients (Table 1). Approximately one third of these patients (2,692, 37.6%), had at least one underlying condition or risk factor. Diabetes mellitus (784, 10.9%), chronic lung disease (656, 9.2%), and cardiovascular disease (647, 9.0%) were the most frequently reported conditions among all cases. Among 457 ICU admissions and 1,037 non-ICU hospitalizations, 358 (78%) and 732 (71%), respectively occurred among persons with one or more reported underlying health condition. In contrast, 1,388 of 5,143 (27%) COVID-19 patients who were not hospitalized were reported to have at least one underlying health condition. FIGURE Daily number of reported COVID-19 cases* — United States, February 12–March 28, 2020† * Cases among persons repatriated to the United States from Wuhan, China, and the Diamond Princess cruise ship are excluded. † Cumulative number of COVID-19 cases reported daily by jurisdictions to CDC using aggregate case count was 122,653 through March 28, 2020. The figure is a histogram, an epidemiologic curve showing the number of COVID-19 cases, by date of report, in the United States during February 12–March 28, 2020. TABLE 1 Reported outcomes among COVID-19 patients of all ages, by hospitalization status, underlying health condition, and risk factor for severe outcome from respiratory infection — United States, February 12–March 28, 2020 Underlying health condition/Risk factor for severe outcomes from respiratory infection (no., % with condition) No. (%) Not hospitalized Hospitalized, non-ICU ICU admission Hospitalization status unknown Total with case report form (N = 74,439) 12,217 5,285 1,069 55,868 Missing or unknown status for all conditions (67,277) 7,074 4,248 612 55,343 Total with completed information (7,162) 5,143 1,037 457 525 One or more conditions (2,692, 37.6%) 1,388 (27) 732 (71) 358 (78) 214 (41) Diabetes mellitus (784, 10.9%) 331 (6) 251 (24) 148 (32) 54 (10) Chronic lung disease* (656, 9.2%) 363 (7) 152 (15) 94 (21) 47 (9) Cardiovascular disease (647, 9.0%) 239 (5) 242 (23) 132 (29) 34 (6) Immunocompromised condition (264, 3.7%) 141 (3) 63 (6) 41 (9) 19 (4) Chronic renal disease (213, 3.0%) 51 (1) 95 (9) 56 (12) 11 (2) Pregnancy (143, 2.0%) 72 (1) 31 (3) 4 (1) 36 (7) Neurologic disorder, neurodevelopmental, intellectual disability (52, 0.7%)† 17 (0.3) 25 (2) 7 (2) 3 (1) Chronic liver disease (41, 0.6%) 24 (1) 9 (1) 7 (2) 1 (0.2) Other chronic disease (1,182, 16.5%)§ 583 (11) 359 (35) 170 (37) 70 (13) Former smoker (165, 2.3%) 80 (2) 45 (4) 33 (7) 7 (1) Current smoker (96, 1.3%) 61 (1) 22 (2) 5 (1) 8 (2) None of the above conditions¶ (4,470, 62.4%) 3,755 (73) 305 (29) 99 (22) 311 (59) Abbreviation: ICU = intensive care unit. * Includes any of the following: asthma, chronic obstructive pulmonary disease, and emphysema. † For neurologic disorder, neurodevelopmental, and intellectual disability, the following information was specified: dementia, memory loss, or Alzheimer’s disease (17); seizure disorder (5); Parkinson’s disease (4); migraine/headache (4); stroke (3); autism (2); aneurysm (2); multiple sclerosis (2); neuropathy (2); hereditary spastic paraplegia (1); myasthenia gravis (1); intracranial hemorrhage (1); and altered mental status (1). § For other chronic disease, the following information was specified: hypertension (113); thyroid disease (37); gastrointestinal disorder (32); hyperlipidemia (29); cancer or history of cancer (29); rheumatologic disorder (19); hematologic disorder (17); obesity (17); arthritis, nonrheumatoid, including not otherwise specified (16); musculoskeletal disorder other than arthritis (10); mental health condition (9); urologic disorder (7); cerebrovascular disease (7); obstructive sleep apnea (7); fibromyalgia (7); gynecologic disorder (6); embolism, pulmonary or venous (5); ophthalmic disorder (2); hypertriglyceridemia (1); endocrine (1); substance abuse disorder (1); dermatologic disorder (1); genetic disorder (1). ¶ All listed chronic conditions, including other chronic disease, were marked as not present. Among patients aged ≥19 years, the percentage of non-ICU hospitalizations was higher among those with underlying health conditions (27.3%–29.8%) than among those without underlying health conditions (7.2%–7.8%); the percentage of cases that resulted in an ICU admission was also higher for those with underlying health conditions (13.3%–14.5%) than those without these conditions (2.2%–2.4%) (Table 2). Small numbers of COVID-19 patients aged <19 years were reported to be hospitalized (48) or admitted to an ICU (eight). In contrast, 335 patients aged <19 years were not hospitalized and 1,342 had missing data on hospitalization. Among all COVID-19 patients with complete information on underlying conditions or risk factors, 184 deaths occurred (all among patients aged ≥19 years); 173 deaths (94%) were reported among patients with at least one underlying condition. TABLE 2 Hospitalization with and without intensive care unit (ICU) admission, by age group among COVID-19 patients aged ≥19 years with and without reported underlying health conditions — United States, February 12–March 28, 2020* Age group (yrs) Hospitalized without ICU admission, No. (% range†) ICU admission, No. (% range†) Underlying condition present/reported§ Underlying condition present/reported§ Yes No Yes No 19–64 285 (18.1–19.9) 197 (6.2–6.7) 134 (8.5–9.4) 58 (1.8–2.0) ≥65 425 (41.7–44.5) 58 (16.8–18.3) 212 (20.8–22.2) 20 (5.8–6.3) Total ≥19 710 (27.3–29.8) 255 (7.2–7.8) 346 (13.3–14.5) 78 (2.2–2.4) * Includes COVID-19 patients aged ≥19 years with known status on underlying conditions. † Lower bound of range = number of persons hospitalized or admitted to an ICU among total in row stratum; upper bound of range = number of persons hospitalized or admitted to an ICU among total in row stratum with known outcome status: hospitalization or ICU admission status. § Includes any of following underlying health conditions or risk factors: chronic lung disease (including asthma, chronic obstructive pulmonary disease, and emphysema); diabetes mellitus; cardiovascular disease; chronic renal disease; chronic liver disease; immunocompromised condition; neurologic disorder, neurodevelopmental, or intellectual disability; pregnancy; current smoker; former smoker; or other chronic disease. Discussion Among 122,653 U.S. COVID-19 cases reported to CDC as of March 28, 2020, 7,162 (5.8%) patients had data available pertaining to underlying health conditions or potential risk factors; among these patients, higher percentages of patients with underlying conditions were admitted to the hospital and to an ICU than patients without reported underlying conditions. These results are consistent with findings from China and Italy, which suggest that patients with underlying health conditions and risk factors, including, but not limited to, diabetes mellitus, hypertension, COPD, coronary artery disease, cerebrovascular disease, chronic renal disease, and smoking, might be at higher risk for severe disease or death from COVID-19 ( 3 , 4 ). This analysis was limited by small numbers and missing data because of the burden placed on reporting health departments with rapidly rising case counts, and these findings might change as additional data become available. It is not yet known whether the severity or level of control of underlying health conditions affects the risk for severe disease associated with COVID-19. Many of these underlying health conditions are common in the United States: based on self-reported 2018 data, the prevalence of diagnosed diabetes among U.S. adults was 10.1% ( 7 ), and the U.S. age-adjusted prevalence of all types of heart disease (excluding hypertension without other heart disease) was 10.6% in 2017 ( 8 ). The age-adjusted prevalence of COPD among U.S. adults is 5.9% ( 9 ), and in 2018, the U.S. estimated prevalence of current asthma among persons of all ages was 7.9% ( 7 ). CDC continues to develop and update resources for persons with underlying health conditions to reduce the risk of acquiring COVID-19 ( 10 ). The estimated higher prevalence of these conditions among those in this early group of U.S. COVID-19 patients and the potentially higher risk for more severe disease from COVID-19 associated with the presence of underlying conditions highlight the importance of COVID-19 prevention in persons with underlying conditions. The findings in this report are subject to at least six limitations. First, these data are preliminary, and the analysis was limited by missing data related to the health department reporting burden associated with rapidly rising case counts and delays in completion of information requiring medical chart review; these findings might change as additional data become available. Information on underlying conditions was only available for 7,162 (5.8%) of 122,653 cases reported to CDC. It cannot be assumed that those with missing information are similar to those with data on either hospitalizations or underlying health conditions. Second, these data are subject to bias in outcome ascertainment because of short follow-up time. Some outcomes might be underestimated, and long-term outcomes cannot be assessed in this analysis. Third, because of the limited availability of testing in many jurisdictions during this period, this analysis is likely biased toward more severe cases, and findings might change as testing becomes more widespread. Fourth, because of the descriptive nature of these data, attack rates among persons with and without underlying health conditions could not be compared, and thus the risk difference of severe disease with COVID-19 between these groups could not be estimated. Fifth, no conclusions could be drawn about underlying conditions that were not included in the case report form or about different conditions that were reported in a single, umbrella category. For example, asthma and COPD were included in a chronic lung disease category. Finally, for some underlying health conditions and risk factors, including neurologic disorders, chronic liver disease, being a current smoker, and pregnancy, few severe outcomes were reported; therefore, conclusions cannot be drawn about the risk for severe COVID-19 among persons in these groups. Persons in the United States with underlying health conditions appear to be at higher risk for more severe COVID-19, consistent with findings from other countries. Persons with underlying health conditions who have symptoms of COVID-19, including fever, cough, or shortness of breath, should immediately contact their health care provider. These persons should take steps to protect themselves from COVID-19, through washing their hands; cleaning and disinfecting high-touch surfaces; and social distancing, including staying at home, avoiding crowds, gatherings, and travel, and avoiding contact with persons who are ill. Maintaining at least a 30-day supply of medication, a 2-week supply of food and other necessities, and knowledge of COVID-19 symptoms are recommended for those with underlying health conditions ( 10 ). All persons should take steps to protect themselves from COVID-19 and to protect others. All persons who are ill should stay home, except to get medical care; should not go to work; and should stay away from others. This is especially important for those who work with persons with underlying conditions or who otherwise are at high risk for severe outcomes from COVID-19. Community mitigation strategies, which aim to slow the spread of COVID-19, are important to protect all persons from COVID-19, especially persons with underlying health conditions and other persons at risk for severe COVID-19–associated disease (https://www.cdc.gov/coronavirus/2019-ncov/downloads/community-mitigation-strategy.pdf). Summary What is already known about this topic? Published reports from China and Italy suggest that risk factors for severe COVID-19 disease include underlying health conditions, but data describing underlying health conditions among U.S. COVID-19 patients have not yet been reported. What is added by this report? Based on preliminary U.S. data, persons with underlying health conditions such as diabetes mellitus, chronic lung disease, and cardiovascular disease, appear to be at higher risk for severe COVID-19–associated disease than persons without these conditions. What are the implications for public health practice? Strategies to protect all persons and especially those with underlying health conditions, including social distancing and handwashing, should be implemented by all communities and all persons to help slow the spread of COVID-19.

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          Urban-Rural County and State Differences in Chronic Obstructive Pulmonary Disease — United States, 2015

          Chronic obstructive pulmonary disease (COPD) accounts for the majority of deaths from chronic lower respiratory diseases, the third leading cause of death in the United States in 2015 and the fourth leading cause in 2016.* Major risk factors include tobacco exposure, occupational and environmental exposures, respiratory infections, and genetics. † State variations in COPD outcomes ( 1 ) suggest that it might be more common in states with large rural areas. To assess urban-rural variations in COPD prevalence, hospitalizations, and mortality; obtain county-level estimates; and update state-level variations in COPD measures, CDC analyzed 2015 data from the Behavioral Risk Factor Surveillance System (BRFSS), Medicare hospital records, and death certificate data from the National Vital Statistics System (NVSS). Overall, 15.5 million adults aged ≥18 years (5.9% age-adjusted prevalence) reported ever receiving a diagnosis of COPD; there were approximately 335,000 Medicare hospitalizations (11.5 per 1,000 Medicare enrollees aged ≥65 years) and 150,350 deaths in which COPD was listed as the underlying cause for persons of all ages (40.3 per 100,000 population). COPD prevalence, Medicare hospitalizations, and deaths were significantly higher among persons living in rural areas than among those living in micropolitan or metropolitan areas. Among seven states in the highest quartile for all three measures, Arkansas, Kentucky, Mississippi, and West Virginia were also in the upper quartile (≥18%) for rural residents. Overcoming barriers to prevention, early diagnosis, treatment, and management of COPD with primary care provider education, Internet access, physical activity and self-management programs, and improved access to pulmonary rehabilitation and oxygen therapy are needed to improve quality of life and reduce COPD mortality. The National Center for Health Statistics (NCHS) 2013 Urban-Rural Classification Scheme for Counties, which uses 2010 U.S. Census population data and the February 2013 Office of Management and Budget designations of metropolitan statistical area, micropolitan statistical area, or noncore area ( 2 ), was used to classify urban-rural status of BRFSS respondents, Medicare inpatient claims, decedents, and populations at risk based on reported county of residence. The six categories include large central metropolitan, large fringe metropolitan, medium metropolitan, small metropolitan, micropolitan, and noncore (rural). Definitions and use of these categories have been described previously ( 2 , 3 ). Prevalence of diagnosed COPD was estimated using the 2015 BRFSS survey, an annual state-based, random-digit–dialed cellular and landline telephone survey of the noninstitutionalized U.S. population aged ≥18 years § that is conducted by state health departments in collaboration with CDC. In 2015, the median survey response rate for the 50 states and District of Columbia (DC) was 46.6% and ranged from 33.9% to 61.1%. ¶ Diagnosed COPD was defined as an affirmative response to the question “Has a doctor, nurse, or other health professional ever told you that you had chronic obstructive pulmonary disease or COPD, emphysema, or chronic bronchitis?” State analyses included 426,838 (98.3%) respondents in the 50 states and DC after exclusions for missing information on COPD or age (Table 1). Urban-rural analyses included 426,736 (98.2%) respondents after excluding those who had missing information for COPD, age, or county code. A multilevel regression and poststratification approach ( 4 ) was used to estimate model-predicted COPD prevalence for U.S. counties in 2015. High internal validity was determined by comparing modeled estimates with actual unweighted BRFSS survey estimates in 1,507 counties with ≥50 respondents (Pearson correlation coefficient = 0.68; p<0.001), and with weighted BRFSS survey estimates in 195 counties with ≥500 respondents and relative standard errors <0.30 (Pearson correlation coefficient = 0.74; p<0.001). Medicare enrollment records and data from 100% of Part A (inpatient hospital) claims in 2015 were obtained from the Centers for Medicare & Medicaid Services. Analyses were limited to 30,212,024 living Medicare Part A enrollees aged ≥65 years who were eligible for fee-for-service hospitalizations on July 1, 2015, and all 335,362 fee-for-service inpatient hospital claims with a first-listed diagnosis of COPD that were submitted in 2015 for Medicare Part A enrollees aged ≥65 years. COPD was defined by International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) codes 490–492 or 496 or ICD-10-CM codes J40–J44.** Urban-rural analyses were limited to 335,102 (99.9%) hospital claims. Mortality data for all ages were analyzed using CDC WONDER, an interactive public-use Web-based tool. †† CDC WONDER mortality data from NVSS contain information from all resident death certificates filed in the 50 states and DC. CDC WONDER queries generated numbers of deaths, age-adjusted death rates, 95% confidence intervals (CIs), and population denominators for groups defined by state and the 2013 NCHS urban-rural classification of decedents. Deaths caused by COPD were defined by ICD-10 codes J40–J44, in which COPD was the underlying cause of death on the death certificate. CDC also obtained population estimates for 2015 from CDC WONDER to calculate the percentage of U.S. and state residents who lived in a rural county as classified by the NCHS 2013 urban-rural county classification. Age-adjusted prevalence of diagnosed COPD for persons aged ≥18 years, Medicare hospitalization rate for persons aged ≥65 years, death rate for all ages, and 95% CI for each estimate were calculated by urban-rural classification and state. For BRFSS analyses, statistical software was used to account for the complex sampling design. Differences in COPD prevalence among rural respondents compared with those of other urban-rural subgroups were determined by t-tests. Urban-rural differences in Medicare hospitalizations and death rates were determined by the Z-test. All two-sided tests were considered statistically significant at α = 0.05. In 2015, approximately 15.5 million adults aged ≥18 years (unadjusted prevalence = 6.3% and age-adjusted prevalence = 5.9%) had self-reported diagnosed COPD. County-level estimates of COPD prevalence ranged from 3.2% to 15.6% (Figure). U.S. counties within the highest quartile of county-level estimates (8.5%−15.6%) tended to be located in nonmetropolitan areas of Alabama, Arizona, Arkansas, Georgia, Kentucky, Maine, Michigan, Missouri, Ohio, Oklahoma, Tennessee, and West Virginia (Figure). FIGURE Unadjusted prevalence of diagnosed chronic obstructive pulmonary disease among adults aged ≥18 years, by county — United States, 2015 The figure above is a U.S. map showing the unadjusted prevalence of diagnosed chronic obstructive pulmonary disease among adults aged ≥18 years, by county, in 2015. Age-adjusted prevalence of diagnosed COPD among adults aged ≥18 years increased with less urbanicity from 4.7% among populations living in large metropolitan centers to 8.2% among adults living in rural areas (Table 1). Medicare hospitalizations (per 1,000 enrollees) for COPD were 11.4 among enrollees aged ≥65 years living in large metropolitan centers and 13.8 among those living in rural areas. Age-adjusted death rates (per 100,000 population) for COPD as the underlying cause also increased with less urbanicity from 32.0 for U.S. residents living in large metropolitan centers to 54.5 for those living in rural areas. There was a consistent pattern for significantly higher estimates of COPD measures from all three independent data systems among adults living in rural areas than among those living in micropolitan or metropolitan areas. TABLE 1 Age-adjusted estimates of selected COPD measures, by urban-rural status of county* — United States, 2015 COPD measure Overall† Large metropolitan center Large fringe metropolitan Medium metropolitan Small metropolitan Micropolitan Noncore (rural) Adult prevalence § BRFSS respondents 426,838 69,442 81,788 92,571 57,415 65,029 60,491 Estimated no. in population (rounded to 1,000s) with diagnosed COPD 15,460,000 3,566,000 3,406,000 3,452,000 1,661,000 1,796,000 1,576,000 % (95% CI) 5.9 (5.8−6.0) 4.7 (4.5−5.0) 5.3 (5.0−5.5) 6.4 (6.2−6.7) 7.0 (6.6−7.3) 7.6 (7.2−8.0) 8.2 (7.8−8.7) Medicare hospitalizations ¶ Number of Medicare enrollees, aged ≥65 years, in fee-for-service plan 30,212,024 6,812,852 7,402,029 6,510,167 3,361,075 3,400,705 2,701,592 Hospital claims with COPD as first-listed diagnosis 335,362 74,616 78,220 68,291 35,798 41,653 36,524 Rate per 1,000 (95% CI) 11.5 (11.4−11.5) 11.4 (11.3−11.5) 11.0 (11.0−11.1) 10.8 (10.7−10.9) 10.9 (10.8−11.0) 12.5 (12.4−12.6) 13.8 (13.6−13.9) Deaths** U.S. population (all ages) 321,418,820 98,997,449 79,867,097 67,041,154 29,346,517 27,260,617 18,905,986 Number of deaths with COPD as underlying cause 150,350 32,309 32,718 33,619 17,419 19,019 15,266 Rate per 100,000 (95% CI) 40.3 (40.1−40.5) 32.0 (31.6−32.3) 36.2 (35.8−36.6) 41.9 (41.5−42.4) 47.0 (46.3−47.7) 52.8 (52.1−53.6) 54.5 (53.6−55.4) Abbreviations: BRFSS = Behavioral Risk Factor Surveillance System; CI = confidence interval; COPD = chronic obstructive pulmonary disease (includes emphysema and chronic bronchitis). * As defined in the National Center for Health Statistics 2013 Urban-Rural Classification Scheme for Counties. † Numbers in urban-rural categories for prevalence and Medicare hospitalizations do not sum to the overall number because 0.02% of eligible BRFSS respondents, 0.08% of eligible Medicare enrollees, and 0.08% of COPD Medicare claims could not be assigned an urban-rural classification. § Percentage ever told by a doctor, nurse, or other health professional that respondent had COPD, emphysema, or chronic bronchitis among adults aged ≥18 years in the 2015 Behavioral Risk Factor Surveillance System survey. Age-adjusted to the 2000 U.S. projected population, aged ≥18 years, using five age groups (18–44, 45–54, 55–64, 65–74, and ≥75 years). ¶ Hospitalizations among adults aged ≥65 years with a first-listed diagnosis claim for COPD International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes 490–492, or 496 or ICD-10-CM codes J40–J44 in the 2015 Medicare Part A hospital claims records. Hospital rates per 1,000 Medicare fee-for-service enrollees aged ≥65 years were age-adjusted to the 2000 U.S. projected population aged ≥65 years, using two age groups (65–74 and ≥75 years). ** Death rate per 100,000 U.S. population (including children) for COPD (ICD-10 codes J40–J44) reported as the underlying cause of death on the death certificate; age-adjusted to the total 2000 U.S. projected population, using 11 age groups (<1, 1–4, 5–14, 15–24, 25–34, 35–44, 45–54, 55–64, 65–74, 75–84, and ≥85 years). Overall 5.9% of U.S. residents lived in rural counties in 2015. State-specific percentages of rural residents ranged from zero percent in Connecticut, Delaware, District of Columbia, New Jersey, and Rhode Island to 34.7% in Montana (Table 2). State-specific age-adjusted prevalence of COPD among adults aged ≥18 years in 2015 ranged from 3.8% in Utah to 12.0% in West Virginia. State-specific age-adjusted Medicare hospitalization rates (per 1,000 enrollees) among enrollees aged ≥65 years ranged from 3.7 in Utah to 19.7 in West Virginia. State-specific age-adjusted death rates (per 100,000 population) in 2015 ranged from 15.8 in Hawaii to 64.3 in Oklahoma. Of the seven states (Alabama, Arkansas, Indiana, Kentucky, Mississippi, Tennessee, and West Virginia) that were in the highest quartiles for all three measures in 2015, four states (Arkansas, Kentucky, Mississippi, and West Virginia) were also in the highest quartile (≥18%) for percentage of rural residents. TABLE 2 Percentage of rural residents and age-adjusted estimates of selected COPD measures, by state — United States, 2015 State % rural residents* Rank order in % rural residents No. in U.S. population with COPD† % (95% CI)§ No. of Medicare hospitalizations¶ Rate per 1,000 (95% CI)¶ No. of deaths Rate per 100,000 (95% CI)** Alabama 12.8 16 393,000 9.9 (9.0−10.9) 7,691 14.3 (14.0−14.6) 3,217 55.2 (53.3−57.1) Alaska 26.1 5 22,000 4.1 (3.3−5.1) 380 6.3 (5.6−6.9) 193 36.1 (30.7−41.6) Arizona 1.5 38 325,000 5.8 (5.2−6.5) 4,711 8.3 (8.1−8.5) 3,570 42.4 (41.0−43.8) Arkansas 19.1 11 219,000 9.1 (8.0−10.5) 4,806 13.3 (12.9−13.7) 2,234 61.3 (58.7−63.8) California 0.7 41 1,207,000 4.0 (3.6−4.4) 20,289 7.9 (7.8−8.1) 13,092 31.8 (31.3−32.4) Colorado 5.6 26 179,000 4.2 (3.8−4.6) 2,376 6.4 (6.1−6.6) 2,514 46.6 (44.8−48.5) Connecticut 0.0 43 143,000 4.6 (4.1−5.1) 3,798 9.7 (9.4−10.0) 1,309 28.4 (26.8−30.0) Delaware 0.0 43 51,000 6.3 (5.3−7.5) 1,137 8.6 (8.1−9.1) 494 40.9 (37.3−44.6) DC 0.0 43 28,000 5.9 (4.9−7.2) 445 7.5 (6.8−8.2) 134 21.5 (17.8−25.2) Florida 1.7 37 1,117,000 6.0 (5.4−6.6) 32,274 15.9 (15.7−16.1) 11,461 37.4 (36.7−38.1) Georgia 7.7 22 532,000 6.7 (6.0−7.6) 9.425 11.9 (11.7−12.2) 4,501 45.7 (44.3−47.1) Hawaii 0.0 43 48,000 4.1 (3.5−4.9) 663 6.2 (5.7−6.7) 303 15.8 (14.0−17.6) Idaho 8.3 21 59,000 4.5 (3.9−5.3) 942 6.3 (5.9−6.7) 817 44.8 (41.7−47.9) Illinois 4.7 29 568,000 5.4 (4.7−6.3) 14,964 11.4 (11.2−11.6) 5,360 36.8 (35.8−37.8) Indiana 7.0 23 400,000 7.4 (6.6−8.3) 9,048 13.1 (12.9−13.4) 4,096 53.7 (52.1−55.4) Iowa 25.2 7 136,000 5.2 (4.6−6.0) 3,407 8.3 (8.0−8.6) 1,949 47.5 (45.4−49.7) Kansas 13.5 15 134,000 5.8 (5.5−6.2) 2,764 8.0 (7.7−8.3) 1,665 48.5 (46.1−50.8) Kentucky 22.3 8 410,000 11.2 (10.2−12.3) 8,618 19.1 (18.7−19.5) 3,280 63.2 (61.1−65.4) Louisiana 7.7 22 265,000 7.1 (6.3−8.0) 5,452 13.5 (13.2−13.9) 2,125 42.1 (40.3−43.9) Maine 31.8 2 86,000 7.0 (6.3−7.8) 1,986 11.3 (10.8−11.8) 1,003 52.5 (49.2−55.8) Maryland 1.4 39 282,000 5.8 (5.1−6.5) 5,841 8.4 (8.2−8.6) 1,945 29.2 (27.9−30.5) Massachusetts 0.2 42 303,000 5.3 (4.8−6.0) 8,566 11.4 (11.2−11.7) 2,668 31.6 (30.4−32.8) Michigan 6.7 24 584,000 6.9 (6.3−7.6) 13,338 13.9 (13.7−14.1) 5,700 46.2 (45.0−47.4) Minnesota 10.5 18 187,000 4.2 (3.8−4.5) 3,910 12.7 (12.3−13.1) 2,273 35.1 (33.7−36.6) Mississippi 22.2 9 173,000 7.2 (6.4−8.2) 5,040 14.3 (13.9−14.7) 1,865 55.3 (52.8−57.8) Missouri 13.7 14 387,000 7.9 (7.1−8.9) 7,587 12.2 (11.9−12.5) 3,843 51.4 (49.8−53.1) Montana 34.7 1 45,000 5.0 (4.3−5.8) 918 7.0 (6.5−7.4) 663 48.8 (45.0−52.5) Nebraska 18.0 12 77,000 5.0 (4.6−5.5) 2,061 8.9 (8.5−9.3) 1,127 50.0 (47.1−53.0) Nevada 1.1 40 145,000 6.2 (5.1−7.6) 2,079 9.0 (8.6−9.4) 1,591 53.2 (50.5−55.8) New Hampshire 3.6 32 70,000 6.1 (5.3−6.9) 1,794 9.5 (9.0−9.9) 681 40.3 (37.3−43.4) New Jersey 0.0 43 341,000 4.6 (4.1−5.1) 10,454 10.1 (9.9−10.3) 3,057 28.2 (27.1−29.2) New Mexico 4.4 30 94,000 5.5 (4.9−6.3) 1,530 8.1 (7.7−8.6) 1,079 43.4 (40.8−46.0) New York 2.0 36 882,000 5.3 (4.8−5.8) 20,489 12.3 (12.2−12.5) 6,755 28.3 (27.6−29.0) North Carolina 6.3 25 573,000 7.0 (6.3−7.7) 10,632 11.2 (11.0−11.4) 5,077 44.1 (42.9−45.3) North Dakota 26.5 4 30,000 4.8 (4.2−5.6) 695 8.4 (7.8−9.0) 340 38.7 (34.5−42.9) Ohio 3.9 31 705,000 7.1 (6.5−7.9) 16,189 16.7 (16.4−16.9) 7,000 48.0 (46.9−49.1) Oklahoma 13.9 13 255,000 8.2 (7.4−9.1) 5,563 12.6 (12.3−12.9) 2,863 64.3 (61.9−66.7) Oregon 2.4 34 174,000 5.1 (4.5−5.8) 2,442 7.6 (7.3−7.9) 2,037 40.7 (38.9−42.5) Pennsylvania 3.2 33 701,000 6.2 (5.5−7.0) 17,795 14.9 (14.7−15.2) 6,457 36.7 (35.8−37.6) Rhode Island 0.0 43 52,000 5.7 (4.9−6.5) 1,435 15.2 (14.4−16.0) 498 35.8 (32.6−39.0) South Carolina 6.3 25 272,000 6.7 (6.1−7.3) 5,666 10.0 (9.7−10.2) 2,828 48.5 (46.6−50.3) South Dakota 25.4 6 36,000 5.2 (4.4−6.1) 976 9.4 (8.8−10.0) 488 44.0 (40.0−47.9) Tennessee 9.8 19 486,000 8.9 (8.0−10.0) 9,875 15.7 (15.3−16.0) 4,151 53.7 (52.1−55.4) Texas 5.1 27 1,032,000 5.1 (4.6−5.7) 22,975 11.7 (11.5−11.9) 9,939 40.2 (39.4−41.0) Utah 4.8 28 75,000 3.8 (3.4−4.3) 683 3.7 (3.4−4.0) 770 32.3 (30.0−34.6) Vermont 26.1 5 31,000 5.6 (4.9−6.3) 660 6.9 (6.4−7.5) 345 41.0 (36.6−45.4) Virginia 9.3 20 374,000 5.5 (5.0−6.0) 7,248 8.1 (7.9−8.2) 3,258 35.8 (34.6−37.1) Washington 2.2 35 335,000 5.8 (5.3−6.3) 3,608 5.4 (5.3−5.6) 3,016 37.9 (36.5−39.3) West Virginia 21.9 10 194,000 12.0 (11.1−13.0) 4,388 19.7 (19.1−20.2) 1,597 63.1 (60.0−66.3) Wisconsin 12.5 17 209,000 4.2 (3.6−4.8) 5,179 10.3 (10.0−10.6) 2,761 38.1 (36.6−39.5) Wyoming 27.4 3 32,000 6.8 (5.9−7.9) 570 7.7 (7.1−8.4) 361 55.9 (50.0−61.7) 50 states and DC 5.9 — 15,460,000 5.9 (5.8−6.0) 335,362 11.5 (11.4−11.5) 150,350 40.3 (40.1−40.5) Abbreviations: BRFSS = Behavioral Risk Factor Surveillance System; CI = confidence interval; COPD = chronic obstructive pulmonary disease (includes emphysema and chronic bronchitis); DC = District of Columbia. *Percentages of residents who live in rural (noncore) counties were calculated from 2015 bridged-race postcensal estimates (July 1, 2015) for populations that were defined by the 2013 National Center for Health Statistics 2013 Urban-Rural Classification Scheme for Counties and obtained from CDC WONDER. † Estimated number of adults with diagnosed COPD rounded to 1,000s. § Percentage ever told by a doctor, nurse, or other health professional that respondent had COPD, emphysema, or chronic bronchitis among adults aged ≥18 years in the 2015 BRFSS survey. Age-adjusted to the 2000 U.S. projected population, aged ≥18 years, using five age groups (18–44, 45–54, 55–64, 65–74, and ≥75 years). ¶ Hospitalizations among adults aged ≥65 years with a first-listed diagnosis claim for COPD International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes 490–492, or 496 or ICD-10-CM codes J40–J44 in the 2015 Medicare Part A hospital claims records. Hospital rates per 1,000 Medicare fee-for-service enrollees aged ≥65 years were age-adjusted to the 2000 U.S. projected population aged ≥65 years, using two age groups (65–74 and ≥75 years). ** Death rate per 100,000 U.S. population (including children) for COPD (ICD-10 codes J40–J44) reported as the underlying cause of death on the death certificate. Age-adjusted to the total 2000 U.S. projected population, using 11 age groups (<1, 1–4, 5–14, 15–24, 25–34, 35–44, 45–54, 55–64, 65–74, 75–84, and ≥85 years). Discussion In 2015, rural U.S. residents experienced higher age-adjusted COPD prevalence, Medicare hospitalizations for COPD as the first-listed diagnosis, and deaths caused by COPD than did residents in micropolitan or metropolitan areas. In addition to the major risk factors for COPD, which include tobacco smoke, environmental and occupational exposures, respiratory infections, and genetics, correlates include older ages, low socioeconomic status, and asthma history ( 5 , 6 ). Rural populations might have higher COPD risk because these populations have a greater proportion with a history of smoking ( 3 ), more secondhand smoke exposure but less access to smoking cessation programs, §§ and higher proportions of uninsured or lower socioeconomic residents, which might have limited access to early diagnosis, treatment, and management of COPD. ¶¶ Rural respiratory exposures might include mold spores, organic toxic dust, and nitrogen dioxide, which are associated with COPD risk ( 7 ). COPD management includes efforts to slow declining lung function, improve exercise tolerance, and prevent and treat exacerbations. Treatments include pulmonary rehabilitation, oxygen therapy, and medications. Smoking cessation programs, routine influenza and pneumococcal vaccinations, regular physical activity, and reductions in occupational and environmental exposures are also important. Barriers to health care in rural areas include cultural perceptions about seeking care, travel distance, absence of services, and financial burden ( 8 ). Access to early diagnosis, prompt treatment, and management of COPD by a pulmonologist is difficult for rural adults with COPD because of limited geographic accessibility to this COPD specialty ( 9 ). Therefore, much of the COPD in rural areas is diagnosed and managed by primary care providers ( 9 ). Level of care and patient-physician communication might vary, given that 27% of adults with COPD symptoms in 2016 reported that they had not talked with their physician about these symptoms ( 10 ). In a primary care physician survey, 71% said that they would use spirometry to assess patients with COPD symptoms, but they also reported that important barriers to diagnosing COPD included patient failure to report COPD symptoms or smoking history, poor treatment adherence, more immediate competing health issues, and diagnostic procedure costs ( 10 ). Whereas 68% of primary care physicians were aware that pulmonary rehabilitation programs were available to their patients, only 38% routinely prescribed this therapy for COPD patients ( 10 ). However, rural areas might have limited availability to these programs. Provision of online health care services (i.e., telemedicine) in rural areas could reduce some of these barriers by providing health education and support websites to patients and caregivers, appointment assistance, and ability to check assessment results online; however, lack of Internet access is still a barrier in some rural populations ( 8 ). The findings in this report are subject to at least eight limitations. First, self-reported diagnosed COPD in BRFSS cannot be validated with medical records and might be subject to recall and social desirability biases; however, urban-rural variations in prevalence were similar to Medicare claims. Second, the BRFSS study population does not include adults who live in long-term care facilities, prisons, and other facilities; thus, findings are not generalizable to those populations. Third, state BRFSS response rates were relatively low, and response rates cannot be obtained by urban-rural classification. This might have resulted in overestimates or underestimates of COPD prevalence; however, a strength is that BRFSS provides large, stable sample sizes for all six urban-rural classifications. Fourth, the assumption that the six urban-rural classifications reflect consistent types of distinct populations and social environments within and across each state could potentially be incorrect. Fifth, county-level estimates are modeled and based on population characteristics such as distributions of older adults in the county; furthermore, it is not known how previous or current local interventions (e.g., tobacco cessation policies and programs) might have affected current COPD prevalence. Sixth, Medicare claims should not be interpreted as unique prevalent cases because some might reflect readmissions; however, these COPD estimates do reflect the actual Medicare burden for hospital facilities, pulmonary rehabilitation services, health care providers, caregivers, and other resources. Seventh, both Medicare hospital claims and death certificates might be subject to reporting preferences for certain diseases as the first-listed or underlying cause if there is a consistent regional or urban-rural preference. Finally, although the data reported here show higher COPD hospitalization and death rates for rural populations, they do not assess whether hospitalization and death rates among patients with COPD vary by urbanicity. Higher burdens of COPD among rural U.S. residents highlight needs for continued tobacco cessation programs and policies to prevent COPD and improve pulmonary function among smokers. Known barriers to care in rural areas suggest a need for improved access for adults with COPD to treatment strategies (pulmonary rehabilitation and oxygen therapy) and comprehensive chronic disease self-management programs. Health care providers and community partners who serve rural residents can help adults with COPD increase access to and participation in health care interventions. Federal agencies are promoting collaborative and coordinated efforts to educate the public, providers, patients, and caregivers about COPD and improve the prevention, diagnosis, and treatment of COPD. The COPD National Action Plan*** includes goals to expand access to online communities, develop clinical decision tools for primary health care providers, and conduct research to improve access to care for COPD in hard-to-reach areas. Promoting these efforts has the potential to improve quality of life for COPD patients and reduce hospital readmissions and COPD mortality. Summary What is already known about this topic? Chronic obstructive pulmonary disease (COPD) is a leading cause of death and has been diagnosed in 15.5 million adults in 2015 in the United States. Risk factors include tobacco exposure, occupational and environmental exposures, respiratory infections, and genetics. What is added by this report? In 2015, rural U.S. residents had higher age-adjusted prevalence of COPD, of Medicare hospitalizations, and deaths caused by COPD than did residents living in micropolitan or metropolitan areas. Several states with the highest percentages of rural populations also had the highest estimates for all three measures. What are the implications for public health practice? Additional efforts are needed to prevent risk factors and overcome barriers to early diagnosis, and the appropriate treatment and management of COPD. Improving access to such health care might improve quality of life and reduce hospital readmissions among COPD patients and reduce COPD mortality.
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            MMWR Morb Mortal Wkly Rep
            MMWR Morb. Mortal. Wkly. Rep
            WR
            Morbidity and Mortality Weekly Report
            Centers for Disease Control and Prevention
            0149-2195
            1545-861X
            03 April 2020
            03 April 2020
            : 69
            : 13
            : 382-386
            Affiliations
            CDC
            CDC
            CDC
            CDC
            CDC
            CDC
            CDC
            CDC
            CDC
            CDC.
            Author notes
            Corresponding author: Katherine Fleming-Dutra, for the CDC COVID-19 Response Team, eocevent294@ 123456cdc.gov , 770-488-7100.
            Article
            mm6913e2
            10.15585/mmwr.mm6913e2
            7119513
            32240123

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