According to recent data, the prevalence of COPD and its related mortality and hospitalization rates have declined in the United States since 1999. However, an estimated 15.7 million Americans people have been diagnosed with COPD, representing more than 6% of the U.S. adult population. In addition, it is suspected that many patients are living with undiagnosed COPD.
National and state-level surveillance data have identified geographic clusters with the highest number of COPD cases, hospitalizations, and mortality. Despite this information, little is known about geographic variations in access to pulmonologists or primary care physicians (PCPs) among patients with COPD and whether they align with these geographic clusters.
Assessing Access to Pulmonologists & Primary Care Physicians
In areas where patients with COPD do not have access to a pulmonologist, it has been assumed that PCPs provide their care. With this in mind, Janet B. Croft, PhD, and colleagues assessed current geographic availability of either pulmonologists or PCPs in the U.S. in order to assess whether adults with COPD would have access to either physician type based on geographic distance. “One of our key objectives was to determine if people with COPD symptoms are being diagnosed early enough for early treatment and management,” adds Dr. Croft.
The study by Dr. Croft and colleagues, published in Chest, identified the practice location of more than 12,000 practicing pulmonologists in the U.S. and more than 248,000 PCPs using the 2013 National Provider Identifier Registry. The researchers then assessed census block-level populations within 5-, 10-, 15-, 20-, 30-, and 50-mile circular distance buffer zones from each provider location in order to determine the percentages of all adults with potential access to at least one provider type.
The researchers used data from the Behavioral Risk Factor Surveillance System (BRFSS)—which collects information on health behaviors, chronic disease, comorbidities, and sociodemographic factors from more than 450,000 Americans annually—to identify the prevalence of the U.S. population with COPD at the county level. “Then, we estimated how far each person with COPD was from the practice locations of each provider type,” adds Dr. Croft.
Pulmonologists Need Help
“In terms of access to PCPs, 100% of people in urban areas, more than 99% in urban clusters, and nearly 92% in rural areas lived within 10 miles of a provider,” says Dr. Croft. More than 99% of all people had access to a PCP within 50 miles. For pulmonologist access, the numbers were less encouraging. While more than 97% of people living in urban areas had access to at least one pulmonologist within 10 miles, only about 38% living in urban clusters and about 35% living in rural areas had such access.
When assessing access to at least one pulmonologist within 50 miles, Dr. Croft and colleagues found that 100% of people in urban areas had access. “However, 1.5 million adults living in urban clusters and 2.2 million adults living in rural areas did not have access to a pulmonologist within 50 miles,” she says. “We identified 222 counties in Midwestern states, some Western states, and along the Rio Grande where adults with COPD did not live within 50 miles of a pulmonologist, meaning these people have to receive their care from PCPs. For those who did live within 50 miles of a pulmonologist, the ratio of patients to pulmonologists reached as high as 6,000:1. Even in some urban areas, the ratio reached 1,600:1 [Figure]. How can a pulmonologist see 1,600 patients?”
It is important to ensure that PCPs follow the same guidelines pulmonologists use for detecting, treating, and managing COPD, according to Dr. Croft. “The BRFSS only captures people who have been diagnosed with COPD,” she says. “There could be twice as many people who have COPD symptoms but who have yet to be diagnosed. Many of these patients will develop severe cases such that they’re hospitalized or die without a diagnosis. It’s possible that many undiagnosed patients live in areas without access to a pulmonologist.”
Patients with COPD often have comorbid conditions—such as heart disease, hypertension, and diabetes—that overshadow COPD. “This may cause PCPs to miss COPD symptoms that pulmonologists would likely identify,” says Dr. Croft. There need to be more linkages between the two provider types. Literature from the United Kingdom suggests that telemedicine may be a possible solution to improving the link between COPD patients and pulmonologists, but more studies are needed to determine if this is an effective strategy.
Dr. Croft says additional questions in surveillance systems like the BRFSS should be developed and ask specifically about COPD symptoms in an effort to improve disease detection rates. “The hope is that the findings from adding these questions would lead researchers to plan more creative studies about detecting and reaching these populations,” she says. “Perhaps cheaper, easier, more portable screening tools could be developed. COPD has become the number three killer in the U.S. largely because of advances in heart disease, cancer, and stroke in terms of detection and preventing death through new technologies and screening tests. It’s time for these advancements to be made for COPD.”
Readings & Resources (click to view)
Croft J, Lu H, Zhang X, Holt J. Geographic accessibility of pulmonologists for adults with COPD. Chest. 2016;150:544-553. Available at http://journal.chestnet.org/article/S0012-3692(16)49011-2/fulltext.
Holt J, Zhang X, Presley-Cantrell L, Croft J. Geographic disparities in chronic obstructive pulmonary disease (COPD) hospitalization among Medicare beneficiaries in the United States. Int J COPD. 2011;61:321-328.
Heins-Nesvold J, Carlson A, King-Schultz L, Joslyn K. Patient identified needs for a chronic obstructive pulmonary disease versus billed services for care received. Int J COPD. 2008;3:415-421.
Ford E, Croft J, Mannino D, Wheaton A, Zhang X, Giles W. COPD surveillance—United States, 1999-2011. Chest. 2013;144:284-305.