NR 503 Week 6 Assignment Epidemiological Analysis

Evaluation Epidemiological Problem: COPD In Kentucky

Chronic obstructive pulmonary disease (COPD) is a chronic lung disease that is a major cause of disability and is the third leading cause of death in the United States (National Heart, Lung, and Blood Institute, 2013). More than 11 million people have been diagnosed with COPD but millions of others live with this chronic disease undiagnosed (American Lung Association, 2016). 

The World Health Organization (WHO) estimated that COPD will rank fifth in the global burden of disease by 2020 (as cited in Kamour, Mannino, & Kanotra, 2015). The prevalence of COPD in the U.S. was 6.1% in 2011 and increased with age (as cited in Kamour, Mannino, & Kanotra, 2015). Worldwide, about 3 million deaths were caused by COPD in 2015 (WHO, 2016).

In the state of Kentucky, lung disease is the third leading cause of death (Centers for Disease Control and Prevention (CDC), 2016b). Kentucky ranked the highest of all 50 states in prevalence of COPD at 9.3% (American Lung Association, 2013). COPD can be prevented in some cases but is not curable once it develops.

This paper will discuss the background of COPD including; definition, description, signs and symptoms, and statistics of COPD; review current surveillance and reporting methods; conduct a descriptive analysis of the epidemiology of COPD; diagnosis, screening and prevention of COPD and a plan to address COPD and measure the outcomes as an advanced practice nurse. Background and Significance of COPD

Definition and Description

COPD refers to a group of chronic lung diseases that cause a blockage in airflow and problems with breathing (CDC, 2016a). The chronic lung diseases that are included in COPD diagnosis are emphysema, chronic bronchitis and occasionally asthma (CDC, 2016a).

COPD affects the airway, air sacs, and lung tissue (American Lung Association, 2016b). COPD causes the airway to become thick and swollen, elasticity of the airway and air sacs to be lost, tissue of the lungs is destroyed and an increase in mucus production causes blockage of the airway (American Lung Association, 2016b).

These effects of COPD increase the demand for oxygen within the body and make simple activities, such as walking, very difficult. Emphysema involves progressive damage of the lung tissue, specifically the alveoli (small air sacs) (American Lung Association, 2013). Chronic bronchitis is chronic inflammation of the bronchi (medium air sacs) that causes a constant cough and excessive mucus production (American Lung Association, 2013).

The main cause of COPD is long term exposure to lung irritants (National Institutes of

Health (NIH), 2013). Smoking, exposure to secondhand smoke and chemical and dust fumes can also contribute to COPD (NIH, 2013). The most common irritant that causes COPD is cigarette smoke (NIH, 2013).

Signs and Symptoms

Most people with COPD notice shortness of breath and inability to do their normal daily activities. The common signs and symptoms of COPD include chronic cough, shortness of breath with daily activities, frequent respiratory infections, fatigue, increase in mucus production, lips and fingernail beds turning blue, and wheezing (American Lung Association, 2016a).

Most people mistake their shortness of breath and inability to perform daily activities as common signs of aging, therefore never seek medical attention. If the symptoms are mild, the person may not notice them and will adjust their lifestyle to make breathing easier. The severity of the symptoms depends on the amount of lung damage present (NIH, 2013).

Statistics of COPD

The prevalence of COPD ranges from state to state. Kentucky ranks the highest with a 9.7% prevalence rate of COPD (American Lung Association, 2013). The overall prevalence rate of COPD in the U.S. is 6.3% and increases with age (Garcia, 2012). COPD was reported more common among non-Hispanic whites (6.3%) and blacks (6.1%) and women (6.7%) were more likely to report COPD than men (5.2%) (Garcia, 2012).

Income also showed an effect on COPD prevalence. The higher the income the lower the prevalence rate. The prevalence rate was also higher in people who had been diagnosed with asthma (20.3%) than those who had not (3.8%) (Garcia, 2012). According to the United Health Foundation (2016a, 2016b) 25.9% of the population are current smokers and 10.1% are exposed to air pollutants.

In 2011, Kentucky was among the top five states for coal production as well (Laney & Weissman, 2014). Below is a table from the CDC (2011) that breaks down the prevalence of adults with COPD in Kentucky using the Behavioral Risk Factor Surveillance System.

Surveillance Method

The CDC collects and analyzes data in order to understand the extent of health risk behaviors, preventative care practices and the burden of chronic diseases to determine the progress of health programs to present to policy makers and public health professionals in order for them to make effective decisions regarding the health of the public (CDC, 2016a).

The types of surveillance used by the CDC are the Behavioral Risk Factors and

Surveillance System (BRFSS), Chronic Disease Indicators (CDI) and Sortable Stats (CDC, 2016a). The two types used for COPD prevalence are the BRFSS and the National Health Interview Survey (American Lung Association, 2013).

The BRFSS is a telephone survey that collects state data regarding the residents’ health-related risk behaviors, chronic health conditions and use of preventative services (CDC, 2016b). This system collects data from all 50 states and the District of Columbia. The BRFSS shows data at the state and national level (CDC, 2016a). The information displayed can be categorized by location or topic (CDC, 2016a). The prevalence rate and trends data for COPD is displayed nationally and by state ranging from year 2011 until 2015 (CDC, 2016 ba). 

For the CDI are a set of surveillance indicators that were developed to help public health professionals and policy makers retrieve state and metropolitan-level data for chronic disease and risk factors that have an immediate effect on public health (CDC, 2016a). These indicators are crucial for surveillance, prioritization and evaluation of interventions at the public level (CDC, 2016a).

The CDI is the only integrated source for state and select large metropolitan areas that includes a wide range of indicators for the surveillance of chronic diseases, conditions and risk factors (CDC, 2016a).

The National Health Interview Survey (NHIS) is conducted by the CDC and the National Center for Health Statistics (American Lung Association, 2013). The information is collected in personal household interviews that provide data to track health status, health care access, and progress towards reaching national objective goals (CDC, 2017). 

The questions asked are “Have you been diagnosed with chronic bronchitis in the past 12 months?” and “Have you ever been diagnosed with emphysema?” (American Lung Association, 2013, pg. 9). This information is displayed using the CDI. There is no mandatory reporting system for those diagnosed with COPD. 

However, hospitals are required to report COPD exacerbations that require an admission to the hospital along with readmissions to the hospital after being discharged within the last 30 days. The Centers for Medicare and Medicaid Services developed hospital outcome measures to help improve the quality of care for COPD patients (Centers for Medicare & Medicaid Services, 2017).

Descriptive Epidemiological Analysis

According to the CDC (2016b) in 2014, almost 15.7 million Americans reported being diagnosed with COPD. The groups most likely to report COPD in 2013 were people aged >65 years old; American Indian, Alaskan Natives and multi-racial non-Hispanics; women; those who were unemployed, retired or unable to work; those with less than a high school education; those who were divorced, widowed, or separated; current or former smokers; and those with a history of asthma (CDC, 2016b).

In the state of Kentucky, 9.8% of individuals reported having been told by a healthcare professional that they have COPD (CDC, 2011). Approximately 120,000 people die from COPD each year and 12 million adults have COPD that is undiagnosed (National Institutes of Health, 2013). In 2010, the medical costs for COPD was estimated at $32.1 billion dollars (Ford et al., 2015). 18% was paid by private insurance, 51% was paid by Medicare and 25% by Medicaid (Ford et al., 2015). The projected medical cost of COPD is $49 billion by 2020 (Ford et al., 2015).

Screening and Diagnosis

Screening for COPD is only recommended for those who are symptomatic. The U.S. Preventative Task Force (USPSTF) recommends that screening for COPD in patients who are asymptomatic does not improve quality of life, morbidity or mortality (Jin, 2016). Early detection of COPD, before symptoms develop, does not alter the course of the disease or improve patient outcomes (Jin, 2016).

Currently, the standard for COPD diagnosis is spirometry testing (CDC, 2011). This test determines how well the lungs are working (Jin, 2016). Air is inhaled and then exhaled quickly and measured using a spirometer (Jin, 2016). This test is completed before and after the administration of a bronchodilator (Jin, 2016). A bronchodilator is inhaled through an inhaler and used in COPD patients to open the airway and decrease secretions (Han, 2016).

To diagnose COPD a thorough health history will be completed by a physician (American Lung Association, 2017). A spirometry will be used to detect COPD or determine the severity of the COPD (American Lung Association, 2017). The physician may also order a chest x-ray and an arterial blood gas test (American Lung Association, 2017).

The chest x-ray will note any changes in the lung size and any abnormalities that can be caused by COPD (Radiological Society of North America, 2016). The arterial blood gas will determine how well the lungs are able to move oxygen into the blood and how well they remove carbon dioxide from the blood (American Lung Association, 2017). The Global Initiative for Chronic Obstructive Lung Disease (GOLD) was formed to promote education and set treatment standards for COPD (Jovinelly & Case-Lo, 2014).

These guidelines indicate that spirometry is essential for diagnosis of COPD (Jovinelly & Case-Lo, 2014). The GOLD criteria was updated and modified in 2014 to include a questionnaire to help diagnose COPD (Luize et al.,2014).

The initial criteria included individuals 45 years and older with a smoking history or individuals of any age with respiratory symptoms (Luize et al., 2014). The modified GOLD criteria included questions about coughing, phlegm production, activity tolerance, age, and smoking status (Luize et al., 2014).

In a study by Luize et al. (2014), the GOLD-modified criteria was used to determine the number of people who met criteria for spirometry testing and compared the sensitivity, specificity, and positive and negative predictive values of the GOLD-modified criteria to others in diagnosing COPD.

The results showed that 2,195 (41.3%) of the people that participated in this study met criteria for the spirometry testing (Luize et al., 2014). The GOLD-modified criteria had a sensitivity of 54.9%, a specificity of 61%, a positive predictive value of 19% and a negative predictive value of 89% (Luize et al., 2014). The GOLD-modified criteria for COPD diagnosis was shown to be the most cost effective method and provided the highest proportion of COPD diagnosis (Luize et al., 2014).

Plan of Action

In developing a plan of action to address this epidemiological disease as an advanced practice nurse, addressing the disease from a primary, secondary and tertiary prevention perspective is needed. To develop a plan of action, understanding the cause of this disease is crucial. As stated above, smoking is the main cause of COPD.

Beginning with a primary preventative plan of action should be started first. Primary prevention aims to prevent the disease from happening (Institute for Work & Health, 2015). This would include communicating with the community, starting at a young age, about the hazards of smoking and the damage made to the body by smoking. Secondary prevention aims to reduce the impact of the disease that has already occurred (Institute for Work & Health, 2015).

This involves smoking cessation and screenings once symptoms of COPD are present. Tertiary prevention aims to soften the impact of the chronic illness (Institute for Work & Health, 2015). This involves managing COPD symptoms. Diagnosing COPD early and obtaining the knowledge to treat COPD effectively is key to managing COPD.

Outcome measurement of this plan of action could be completed by questionnaires that are mailed out post-office visit. Asking about smoking status and if adequate education was provided during the visit would help to address the primary prevention plan of action. Outcome measurement of secondary prevention would be addressing smoking status each visit at the clinic and asking the GOLD-modified criteria questions to determine when the appropriate time for spirometry screening should begin. 

Measuring the tertiary prevention outcome would be following the readmission rates to the hospital for COPD exacerbation as well as the frequency of visits needed to manage the patient’s treatment plan for patients that are seen in the clinic. Also, making physician referrals to manage the disease would benefit the patient and minimize exacerbations of the disease.

A study completed by Agarwai, Zhang, Kuo, & Sharma (2016) found that, patients who were cared for by an advanced practice nurse (APN) were more likely to receive short acting bronchodilators, oxygen therapy and have pulmonologist referrals made. The use of resources by the APN demonstrated a lower trend in emergency visits and readmissions (Agarwai, Zhang, Kuo, & Sharma, 2016). This outcome measurement confirms that with proper knowledge of COPD treatment and ample use of resources, a plan of action can be set and executed.


In summary, COPD affects more than 11 million people (American Lung Association,

2016). Kentucky has the highest prevalence rate of COPD of all 50 states (American Lung Association, 2013). Air pollution, cigarette smoke, secondhand smoke, and dust and chemical fumes (often work-related) cause COPD (American Lung Association, 2016). Therefore, education on prevention of lung irritants is essential.

Lack of awareness of the disease and its symptoms prevent individuals from seeking advice from health care providers. Most doctors agree that compliance with medication regimens and inability to stop smoking were the most common barriers for COPD treatment (Kaur, Aggarwal, & Gogtay, 2016). This indicates that further education is needed for those diagnosed with COPD. Primary prevention of smoking would be the best route to rid this epidemiological problem.