COPD in Los Angeles County: A Call to COPD in Los Angeles County: A Call to

ActionAction

Jonathan Fielding, MD, MPH, MA, MBAJonathan Fielding, MD, MPH, MA, MBA

Director and Health OfficerDirector and Health Officer

Los Angeles County Department of Public HealthLos Angeles County Department of Public Health

November 20, 2013November 20, 2013

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• Vision: Vision: Healthy People in Healthy CommunitiesHealthy People in Healthy Communities

• Mission: Mission: To protect health, To protect health, prevent disease, and promoteprevent disease, and promotehealth and well-being health and well-being

• Departmental Stats:Departmental Stats:– Annual budget over $850 millionAnnual budget over $850 million– Nearly 4,000 employeesNearly 4,000 employees

Los Angeles CountyLos Angeles CountyDepartment of Public HealthDepartment of Public Health

How Many Persons in Los Angeles How Many Persons in Los Angeles County Are Currently Living with COPD?County Are Currently Living with COPD?

• 2005 LA County Health Survey: Have you ever been told by a doctor that you have a chronic respiratory condition, such as emphysema or chronic bronchitis, that lasted 3 months or longer?

- 300,000 (4.0%)

• 2005 CHIS: Have you ever been told that you have lung disease other than asthma?

- 105,000 (1.4%)

• 2011 BRFSS: Have you ever been told by a doctor or health professional that you have COPD, emphysema or chronic bronchitis?

- 197,000 (3.1%)

2. Source: 2005 California Health Interview Survey.

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Age-adjusted rate/100,000

Cause of Death 2001 2010 % Change from 2001

Coronary heart disease 220 138 -37%

Stroke 56 36 -36%

Lung cancer 42 33 -21%

COPD 36 30 -17%

Alzheimer’s disease 12 25 108%

Pneumonia & influenza 32 22 -31%

Diabetes 24 21 -13%

Colorectal cancer 18 14 -22%

Chronic liver disease 12 12 0%

Breast cancer (female) 24 21 -13%

Source: Office of Health Assessment and Epidemiology, Los Angeles County Department of Public Health

Trends in the Leading Causes of Death Trends in the Leading Causes of Death Los Angeles County, 2001-2010Los Angeles County, 2001-2010

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COPD Mortality by Gender and COPD Mortality by Gender and Race/Ethnicity, Los Angeles County, 2010Race/Ethnicity, Los Angeles County, 2010

Source: California DPH Death Statistical Master File for Los Angeles County Residents, 20105

COPD Mortality by Service Planning Area COPD Mortality by Service Planning Area Los Angeles County, 2010Los Angeles County, 2010

Source: California DPH Death Statistical Master File for Los Angeles County Residents, 20106

Risk Factors for COPDRisk Factors for COPD

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• Smoking and second-hand smoke exposure (the major preventable cause)

• Exposure to air pollutants (ambient, workplace, home)

• Genetic factors

• Respiratory infections

• Other?

California a Leader in Tobacco ControlCalifornia a Leader in Tobacco Control

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• First state to pass a tobacco tax (1988), though we have since fallen behind—the tobacco tax rate in California is now below the national average:

─ California’s tax rate $0.87 vs. U.S. average of $1.53 (NY’s is $4.35)

• Smoke-free workplace law (1995)

• Smoke-free restaurant law (1995)

• Smoke-free bar law (1998)

• Hard-hitting counter-advertising campaigns

Local (City and County) Tobacco Control Local (City and County) Tobacco Control Policies Adopted in LA County, 2004-2013Policies Adopted in LA County, 2004-2013

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Prevalence of Cigarette Smoking Among Prevalence of Cigarette Smoking Among Adults (18 years and older), Adults (18 years and older),

Los Angeles County, 1997-2011Los Angeles County, 1997-2011

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a. prevalence based on current use of cigarettesb. prevalence based on current use of cigarettes and having smoked 100 lifetime cigarettesc. Sample includes cell phone users

Source: LA County Health Survey

Percentage of Adult Cigarette Smokers by Percentage of Adult Cigarette Smokers by

Gender and Race/Ethnicity Gender and Race/Ethnicity Los Angeles County, 2011Los Angeles County, 2011

*The estimate is statistically unstable (relative standard error >23%)Source: Los Angeles County Health Survey, Department of Public Health

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Smoking CessationSmoking Cessation

• Ask, Advise, and Refer• 1.800.No Butts (800.662.8887) • California Smokers' Helpline is a telephone program that

can help persons quit smoking. Helpline services are free and are offered in English, Spanish, Cantonese, Vietnamese, Korean, and TTY/TDD.

• LA County’s website, www.laquits.com, provides additional information and tips for living tobacco-free.

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Trends in COPD MortalityTrends in COPD Mortality1979-20101979-2010

Source: CDC, National Center for Health Statistics13

Trends in Lung Cancer MortalityTrends in Lung Cancer Mortality1979-20101979-2010

Source: CDC, National Center for Health Statistics14

Health Impacts of Air Pollution in Health Impacts of Air Pollution in Southern California (per year)Southern California (per year)

Data Source: South Coast Air Quality Management District, 2010, http://www.aqmd.gov/ej/CAC/health_impacts.htm

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Ozone Trends: Los Angeles CountyOzone Trends: Los Angeles County

Source: http://www.arb.ca.gov/adam/trends/trends1.php

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PM 2.5 Trends: Los Angeles CountyPM 2.5 Trends: Los Angeles County

Source: http://www.arb.ca.gov/adam/trends/trends1.php

Reducing Near-Roadway ExposuresReducing Near-Roadway Exposures

• CARB advisory, 2005

- avoid siting new sensitive land uses within 500 ft of a freeway, urban roads with 100,000 vehicles/day, or rural roads with 50,000 vehicles per day

- "sensitive land uses" include residences, schools, child care centers, playgrounds, and medical facilities

- is voluntary ("Land use agencies have to balance other considerations, including housing and transportation

needs, economic development priorities, and other quality of life issues.")

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Broader Policy Action NeededBroader Policy Action Needed

• Stronger mandates for use of zero emission and low emission vehicles, including trucks used for goods movement

• Alternative goods movement strategies

• Establish regulatory standards for near roadway emissions

• Increase mass transit options

• Promote land use practices that reduce auto dependence

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Opportunities in the Health Reform EraOpportunities in the Health Reform Era

• Landmark policy changes provide new opportunities for prevention, early detection and treatment: Expanded access to coverage No-cost preventive services Primary care medical homes Increased accountability for outcomes

• We must maximize those opportunities given the: – growth of our aging population (in LA County, people aged 65+

are projected to grow from 1.1 million in 2010, to 2.2 million in 20301);

– persistence of health inequities; and

– burden of COPD and other chronic conditions.1) Kao, DT & Lloyd, DA. Los Angeles Population Change and Healthy Aging. Los Angeles, CA: USC Roybal Institute on Aging, 2010

Prevention Opportunities from Prevention Opportunities from Community Transformation GrantCommunity Transformation Grant

• Funding period: 2012 to 2017• Funding amount: $49 million

– Active Living & Healthy Eating• e.g. active transportation, school

meals, sugar sweetened beverageconsumption

– Tobacco Free Living • e.g. nicotine addiction screening,

smoking cessation services

─ High Impact Clinical & Other Preventive Services • e.g. blood pressure screenings, aspirin use screenings

─ Health Marketing • e.g. paid media placements, social media, and public education

through print materials21

Several Key Affordable Care Act ProvisionsSeveral Key Affordable Care Act Provisions

• Section 3025 of ACA requires Centers for Medicare and Medicaid Services (CMS) to reduce payments to Inpatient Prospective Payment System (IPPS) hospitals with excess readmissions.

• In Fiscal Year 2015, CMS is finalizing the expansion of the applicable conditions to include patients admitted for an acute exacerbation of COPD.

• The ACA supports comparative effectiveness research by establishing a non-profit Patient-Centered Outcomes Research Institute (PCORI).

• PCORI will help identify clinically effective COPD treatments and diagnostic tests.

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Additional Potential Benefits of ACA for Additional Potential Benefits of ACA for Persons with COPDPersons with COPD

• Insurance companies may not drop patients due to an illness or condition nor exclude patients based on pre-existing conditions

• More support available for preventive services, including smoking cessation

• Emphasis on primary care medical homes and increased coordination between care providers; use of electronic medical records to support care coordination

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Major Actions NeededMajor Actions Needed

• Enhanced surveillance to better characterize the toll of COPD and assess the effectiveness of prevention and treatment efforts moving forward

• Improved systems of care to increase early detection and linkage to high-quality medical services.

• Improved coordination of medical and other support services.

• Continued focus on community-based prevention—tobacco control, air pollution reduction, workplace protection.

• Increased investment in research to identity more effective treatments and prevention strategies

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