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.