Chronic obstructive pulmonary disease (COPD) is a complex lung disease characterized
by airways inflammation and lung tissue remodeling, leading to loss of small airways
and emphysema.1 It is the fourth leading cause of death in the United States, responsible
for more than 150,000 deaths yearly.2 More than 15 million people have been diagnosed
with COPD and, compared to 4.7% in large metropolitan areas, a staggering 8.2% of
those living in rural areas have the disease.2 That translates to about 3.5 million
people, and it does not include the estimated additional 1 million undiagnosed.2,
3 Notably, even among never‐smokers, rural residence and poverty are risk factors
for COPD.4 The disease also takes a heavy financial toll: national medical costs associated
with COPD are projected to increase from $32.1 billion in 2010 to $49 billion in 2020.5
To tackle COPD, Congress requested that federal and nonfederal partners develop a
plan and identify the specific efforts patients, advocates, health care professionals,
educators, payors, researchers, the biomedical industry, and federal agencies must
take to change the course of COPD. The COPD National Action Plan (CNAP) was released
during the 2017 American Thoracic Society International Conference.6 To address COPD
in rural populations through the lens of the CNAP, the Health Resources and Services
Administration (HRSA) and the National Heart, Lung, and Blood Institute (NHLBI) convened
a workshop of rural health representatives and COPD stakeholders in Bethesda, Maryland,
on March 19, 2018, to discuss ways to implement each of the 5 goals of the CNAP in
rural settings. Below is a summary of the discussions held at the meeting.
Goal 1: Empower People with COPD, Their Families, and Caregivers to Recognize and
Reduce the Burden of COPD
Educating patients and their caregivers (usually family members) about COPD is the
cornerstone of Goal 1. While patient education generally happens in health care facilities,
COPD awareness, diagnosis, and care for rural populations also need to reach locations
unique to rural settings. Partnering with national rural‐focused entities such as
the American Agri‐Women (AAW) Association, the National Future Farmers of America
Organization, Sigma Alpha (a professional agricultural business sorority), and other
members of the Consortium of Collegiate Agricultural Organizations can offer additional
opportunities to educate about COPD and its prevention. Recognizing rural heterogeneity,
culturally, linguistically, and content‐appropriate messages need to be crafted for
each targeted region. To be sustainable, these programs must develop—with adequate
regional, state, and national assistance—local champions. Support could come from
groups such as the COPD Foundation, the American Lung Association (ALA), AAW, the
National Rural Health Association (NRHA), HRSA's Federal Office of Rural Health Policy,
the Veteran Administrations’ Office of Rural Health, the Centers for Medicare and
Medicaid Services, the states’ Primary Care Associations (PCAs), the National Association
of Rural Health Clinics, and the National Association of Community Health Centers.
Goal 2: Improve the Prevention, Diagnosis, Treatment, and Management of COPD by Improving
the Quality of Care Delivered Across the Health Care Continuum
Goal 2 of the CNAP stresses the importance of developing and disseminating patient‐centric,
clinical practice guidelines that health care professionals can use to deliver COPD
care. These will help primary care clinicians who are the providers of care to most
people with COPD in rural areas, as these communities often lack pulmonologists.7
In rural settings, telehealth, telemedicine, telemonitoring, and telementoring can
help relieve isolation, support appropriate education, and assist in patient care.
Addressing reimbursement issues to support multidisciplinary team care to incentivize
cost‐effective interventions, such as pulmonary rehabilitation (PR), is also important.
Additional resources available are the pocket guide based on the Global initiative
for chronic Obstructive Lung Disease guidelines,8 and the COPD Foundation pocket guide
and app.9 Electronic health records, such as those used in the VA's electronic health
record (Vista/CPRS) system, also hold promise.10 Structured longitudinal telementoring
of rural health care professionals, including medical assistants, respiratory therapists,
and home health care professionals, could create a virtual “community of practice”
that would facilitate COPD team management in rural areas. The strategy of “moving
knowledge” instead of “moving patients” has been shown to be effective in managing
other chronic diseases in medically underserved areas using the Extension for Community
Health Outcomes model for telementoring.11, 12 Many rural areas have been federally
designated as medically underserved in part because primary care there is provided
by other health professionals, including nurse practitioners and physician assistants.13
Increasing the availability of other professionals, such as respiratory therapists,
would provide important services to patients and families affected by COPD such as
training in the use of inhalers,14 and delivery of PR, which improves patient clinical
COPD outcomes but requires continued physical activity after initial program completion.15
These therapies are underutilized due to insufficient funding, resources, and reimbursement
but also lack of awareness and knowledge by health care professionals, payors, and
patients,15 and their delivery is often complicated by the long distances that rural
COPD patients must travel to access them.16 Programs such as the Appalachian Pulmonary
Health Project offer an example of successful delivery of a comprehensive outpatient
PR in rural settings.17 PR structures also offer the opportunity to deliver tobacco
cessation interventions and pulmonary function testing such as spirometry, which plays
a necessary role in the diagnosis and assessment of severity of COPD.18 Potential
alternatives, such as rehabilitation at home or telehealth rehabilitation with remote
online supervision, are currently being tested.19
Goal 3: Collect, Analyze, Report, and Disseminate COPD‐Related Public Health Data
that Drive Change and Track Progress
Goal 3 of the CNAP stresses the importance of delivering interventions based on evidence
from the regions and populations to be served. Access to timely, comprehensive COPD
data is foundational to identifying where to best target resources for rural patients’
and health care providers’ education, worksite wellness programs, and prevention programs,
and to reduce disease burden. Although national COPD data are available, most rural‐specific
data are not easily accessible at the local level. In addition, because the Centers
for Disease Control and Prevention (CDC) does not fund COPD programs, state and local
public health departments have no local CDC‐generated data to use. An alternative
source for gathering COPD data in rural communities is through accountable care organizations
(ACOs).20, 21 Because COPD‐related health care costs due to disease flare‐ups are
very high (e.g., they require more ED visits, hospital admissions, and readmissions),
ACOs are demonstrating that it is cost effective to monitor and manage COPD to prevent
or minimize acute episodes. The ACO data that are used to monitor COPD care and patients’
outcomes could be aggregated to support collaborative efforts in rural communities.
Existing annual databases can also provide rural data on COPD. Public access to http://wonder.cdc.gov
provides annual death certificate information from the National Vital Statistics System,
run by the National Center for Health Statistics. County‐level prevalence of COPD
and other chronic conditions among annual Medicare fee‐for‐service enrollees may be
accessed at http://www.cms.gov. Urban‐rural categories data can be analyzed using
the Federal Information Processing Specification county code.22 Address locations
of providers and specialists who submit Medicare and Medicaid claims may be obtained
from the National Provider Identifier Registry (http://www.cms.gov). Self‐reported
doctor‐diagnosed COPD, other chronic diseases, risk factors, and sociodemographic
characteristics from the annual Behavioral Risk Factor Surveillance System may be
obtained at http://www.cdc.gov/brfss and http://www.cdc.gov/cdi. To facilitate the
analysis and use of these fragmented data sources, it is imperative to continue to
create accessible linkages to the rural communities, and a CDC data portal with downloadable
county‐level COPD data would be useful for promoting rural efforts.
Goal 4: Increase and Sustain Research to Better Understand the Prevention, Pathogenesis,
Diagnosis, Treatment, and Management of COPD
Goal 4 of the CNAP aims at fostering all aspects of COPD research. For example, cigarette
smoking is a prime target for intervention not only because it is responsible for
75% of COPD cases nationally, but also because it disproportionately impacts rural
residents.23 Less access to public education programs that teach the dangers of smoking
and its connection with COPD must be corrected through the implementation of tobacco
use prevention and cessation programs.24, 25 Additionally, up to 25% of patients with
COPD report having never smoked,26 and data collected from these individuals identify
occupational and environmental exposures such as passive smoke, biomass fuels used
for cooking and heating, mining dusts, or agricultural biodusts.26 Research is needed
to further clarify the roles of additional agents as possible causes of airflow obstruction
and lung tissue damage and to document the effectiveness of exposure reduction strategies
in preventing COPD.27, 28, 29 To this end, the participation of individuals from rural
communities in registries and clinical trials conducted in rural settings is key to
delivering meaningful results. Research on evidence‐based models for preventing, diagnosing,
and treating COPD in rural practices can be facilitated, for example, through partnerships
between COPD researchers and Primary Care Practice‐based Research Networks (PBRNs).30
Currently, 5 PBRNs are participating in the NHLBI‐funded CAPTURE COPD study aimed
at validating the sensitivity, specificity, and predictive value of a 5‐item survey
and a peak expiratory flow measurement to identify patients with undiagnosed, clinically
significant COPD.31 Additional opportunities to facilitate and enhance COPD research
in rural settings could stem from public‐private partnerships, including those with
industry, and the use of different models of diagnostic and therapeutic delivery.
Text message‐based smoking cessation interventions are effective and can be beneficial
for rural residents,32 and telemedicine is an attractive option for providing COPD
care to rural patients.33 PR, including home‐based PR, could also be delivered through
telehealth.19, 34 Local health care professionals and national patient advocacy groups
could help increase participation of rural residents in research and clinical trials.35
Goal 5: Translate National Policy, Educational, and Program Recommendations into Research
and Public Health Care Actions
Goal 5 calls for implementation of the CNAP, including in rural settings, and translating
national COPD strategies into state‐ and community‐based initiatives. This requires
a multipronged approach and sustained efforts from all interested parties. Federal
agencies that provide health care‐related grants to states, such as NIH, HRSA, CDC,
Patient‐Centered Outcomes Research Institute, the Agency for Healthcare Research and
Quality, the US Department of Agriculture, and others, must integrate COPD into their
programs, and they need to fully engage state governments and agencies in COPD initiatives.
In turn, states could be required or incentivized to engage in interagency collaborations
to address COPD. Barriers to collaboration need to be removed to facilitate partnerships,
including those with drug and device industries. These stipulations must be reflected
in funding announcements, along with the economic, cultural, social, geographic, and
demographic characteristics of rural communities. Rural patients could be organized
around local chapters of national support groups, such as the ALA Better Breathers
Clubs, the COPD Foundation State Captains and Harmonicas for Health, and other groups
sponsored by existing trusted partners. State and federal health services agencies
could educate and engage existing health and social service advocacy organizations
(e.g., the NRHA, state rural health associations, state hospital associations, state
offices of rural health, PCAs, county medical associations, and Community Action Agencies)
to incorporate COPD in their messaging. Medicare Rural Hospital Flexibility grant
funding could be leveraged to engage and track patients with COPD. State, local, and
tribal health departments and organizations could prioritize COPD education and referrals,
and health centers could institute COPD measures in the set collected by Federally
Qualified Health Centers and Rural Health Clinics. Notably, a demonstrated return
on investment (ROI) could pave the way for increased job opportunities in rural settings
(e.g., for respiratory therapists, nurses, pharmacists, community health workers,
physician assistants). Finally, organizations such as the National Governors Association
and the National Conference of State Legislatures should recognize the significance
of COPD, encourage governors and state legislators to pass legislation that addresses
the disease, and ensure that each state has a well‐articulated COPD plan that outlines
specific strategies, including those addressing workforce shortages.
Conclusion
COPD is a common, underdiagnosed, undertreated, and devastating chronic lung disease
prevalently affecting underserved communities such as those of rural America. A concerted
effort from all interested parties will make a difference in the lives of people and
families affected by COPD and the communities in which they live.