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Original Research: COPD |

Changes in Mortality Among US Adults With COPD in Two National Cohorts Recruited From 1971-1975 and 1988-1994Changes in Mortality in US Adults With COPD FREE TO VIEW

Earl S. Ford, MD, MPH; David M. Mannino, MD, FCCP; Guixiang Zhao, MD, PhD; Chaoyang Li, MD, PhD; Janet B. Croft, PhD
Author and Funding Information

From the Division of Adult and Community Health (Drs Ford, Zhao, and Croft), National Center for Chronic Disease Prevention and Health Promotion, and Division of Behavioral Surveillance (Dr Li), Public Health Surveillance Program Office, Centers for Disease Control and Prevention, Atlanta, GA; and Department of Medicine (Dr Mannino), University of Kentucky College of Medicine, Lexington, KY.

Correspondence to: Earl S. Ford, MD, MPH, Centers for Disease Control and Prevention, 4770 Buford Hwy, MS K67, Atlanta, GA 30341; e-mail: eford@cdc.gov


Funding/Support: The authors have reported to CHEST that no funding was received for this study.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2012 American College of Chest Physicians


Chest. 2012;141(1):101-110. doi:10.1378/chest.11-0472
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Background:  COPD is a major contributor to the global burden of disease. Our objective was to examine changes in the mortality rate among persons with COPD in the United States.

Methods:  We conducted prospective studies using data from 5,185 participants in the National Health and Nutrition Examination Survey (NHANES) I Epidemiologic Follow-up Study (baseline examination from 1971-1975; follow-up from 1992-1993) and 10,954 participants of the NHANES III Linked Mortality Study (baseline examination from 1988-1994; follow-up through 2006).

Results:  The age-adjusted rate (per 1,000 person-years) among participants with moderate or severe COPD (23.9 and 20.2) was about 2.5 to 3 times higher than the rate among participants with normal lung function (10.4 and 6.2) in NHANES I and NHANES III, respectively. Compared with NHANES I, the mortality rate among participants in NHANES III decreased by 15.8% for those with moderate or severe COPD, 25.2% for those with mild COPD, 35.9% for those with respiratory symptoms with normal lung function, 16.6% for those with restrictive impairment, and 40.1% for those with normal lung function. However, the decrease did not reach statistical significance among participants with moderate or severe COPD. The decreases in the mortality rate among men with moderate or severe COPD (−17.8%) or with restrictive impairment (−35.1%) exceeded the changes among women (+3% and −6.1%, respectively).

Conclusions:  The secular decline in the mortality rate in the United States benefited people with COPD less than those with normal lung function.

Figures in this Article

COPD is a major cause of morbidity and mortality in the United States and elsewhere and is counted among the principal contributors to the global burden of disease.1 In 2008, ∼ 12.1 million adults in the United States were estimated to have COPD as diagnosed by a physician.2 Almost 121,000 deaths were attributed to COPD in 2006, making COPD the fourth leading cause of mortality.2 Approximately 670,000 hospitalizations showed COPD as the first-listed discharge.3 Furthermore, COPD exacts a heavy toll on the quality of life. The economic costs from this disease that were estimated at $23.9 billion in 1993 were projected to have been $49.9 billion in 2010.3

Among men in the United States, the mortality rate from COPD determined from vital statistics data increased steadily from the 1960s through the 1980s, leveled off during the 1990s, and started to decrease during the mid to late 1990s.3 Among women, the mortality rate increased steadily until about the year 2000 and has remained more or less stable through 2006. Two factors may have contributed to the decline in men and the stabilization of the mortality rate in women. First, the prevalence of COPD may have declined, as shown by the percentages of adults reporting having physician-diagnosed COPD.3 Second, mortality among persons with COPD, which for those with severe COPD is about double that of those without this disease,4,5 may have changed over time. Because little is known about this latter possibility, the objective of the present study was to examine changes in the mortality rate in two cohorts of nationally representative adults in the United States separated by about 13 years.

We used data from the National Health and Nutrition Examination Survey (NHANES) I Epidemiologic Follow-up Study (baseline examination from 1971-1975; follow-up through part of 1993) and the NHANES III Linked Mortality study (baseline examination from 1988-1994; follow-up through 2006).6,7 Participants of the original surveys were selected by use of a stratified multistage probability sample and were deemed to be representative of the civilian noninstitutionalized population in the United States. Participants who agreed to participate in the surveys were interviewed in their homes and invited for an examination in the mobile examination center where they were asked to complete additional questionnaires, to undergo various examinations, and to provide a blood sample. NHANES I underwent internal human subjects review, and NHANES III received Institutional Review Board approval.

Attempts were made to contact NHANES I participants from 1982 to 1984 as well as in 1985, 1986, and 1992. Consequently, some participants were identified as being lost to follow-up. NHANES III participants were not contacted, and those who were not deemed to have died were considered to be alive. The mortality status of participants was determined through a match with records of the National Death Index. For NHANES I participants, other tracing methods also were used to identify deaths. Diseases of the circulatory system were identified by using International Classification of Diseases, Ninth Revision codes 390 to 458 and International Classification of Diseases, Tenth Revision codes I00 to I99.

A sample of adults attending the mobile examination center in NHANES I and all adults in NHANES III were offered a pulmonary function test. These methods are described elsewhere.4,8 We used the GOLD (Global Initiative for Chronic Obstructive Lung Disease) classification to create the following categories: severe COPD FEV1/ FVC < 0.70 and FEV1 < 50% predicted), moderate COPD (FEV1/FVC < 0.70 and FEV1 50% to < 80% predicted), mild COPD (FEV1/FVC < 0.70 and FEV1 ≥ 80%), symptoms only (presence of respiratory symptoms in the absence of any lung function abnormality), restrictive impairment (FEV1/FVC ≥ 0.70 and FVC < 80% predicted), and normal lung function. To increase sample size, participants with moderate or severe COPD were combined. In both NHANES I and NHANES III, the presence of respiratory symptoms comprised a positive response to at least one question about cough, phlegm production, wheeze, or dyspnea, although the wording of the questions differed between surveys.4,9 Covariates included age, sex, self-reported race or ethnicity (white, black, and other); educational level; smoking status; systolic BP; total cholesterol; BMI; and history of diabetes, myocardial infarction, and stroke.

The analyses were limited to participants aged 25 to 74 years in both surveys because persons of this age range constituted the original group of NHANES I participants who were subject to follow-up. Mortality rates were calculated per 1,000 person-years of survival time. Age adjustment was done to the projected year 2000 US population for adults aged 25 to 74 years using the direct method. Differences in age-adjusted mortality rates were tested with a t test. Log-linear regression was used to compare adjusted mortality rates after adjusting for age. Proportional hazards analysis was used to estimate hazard ratios for different levels of the GOLD classification. Analyses were conducted with SAS (SAS Institute) and SUDAAN (RTI International) statistical software, the latter to account for the complex sampling design of the surveys.

Of the 6,902 NHANES I participants aged 25 to 74 years who attended the mobile examination center, 5,533 were assigned a GOLD classification. Exclusions of missing values of study variables and loss to follow-up reduced the sample to 5,185 participants. Of the 12,831 eligible NHANES III participants aged 25 to 74 years who attended the mobile examination center, 12,016 were assigned a GOLD classification. After exclusions of missing values of other study variables, 10,954 NHANES III participants were included in the analytic sample.

Several significant differences in study variables were found in the comparison of participants from NHANES I and III. Compared with participants of NHANES III, NHANES I participants were older, more likely to be white, had less education, were more likely to be a current smoker, had a higher mean systolic BP and mean concentration of total cholesterol, had a lower mean BMI, and were less likely to report having diabetes. Descriptive data by GOLD classification status are shown in Table 1.

Table Graphic Jump Location
Table 1 —Unadjusted Means and Percentages for Selected Baseline Characteristics Among Adults Aged 25-74 Years in the United States by GOLD Classification

Data are presented as mean ± SE. To convert total cholesterol from mg/dL to mmol/L, multiply by 0.0259. NHANES = National Health and Nutrition Examination Survey.

a 

Does not meet the standard of statistical reliability and precision (relative SE ≥ 30%).

Among the 5,185 participants of NHANES I, 8.1% had moderate or severe COPD, 7.4% had mild COPD, and 8.9% had restrictive impairment (Fig 1). Among the 10,954 participants of NHANES III with a pulmonary function test, 7.1% had moderate or severe COPD, 7.2% had mild COPD, and 8.0% had restrictive impairment (Fig 1). The percentage of participants with moderate or severe COPD, mild COPD, or restrictive impairment did not differ significantly between the two surveys. However, 15.8% of participants in NHANES I had respiratory symptoms compared with 24.5% of participants in NHANES III (P < .001).

Figure Jump LinkFigure 1. Unadjusted distribution of categories of GOLD (Global Initiative for Chronic Obstructive Lung Disease) classification among adults aged 25 to 74 years in the United States, by survey and sex. NHANES = National Health and Nutrition Examination Survey.Grahic Jump Location

Among the 5,185 eligible NHANES I participants, 1,280 deaths were recorded (596 deaths due to diseases of the circulatory system). Among the 10,954 eligible NHANES III participants, 1,923 deaths were recorded (738 deaths due to diseases of the circulatory system).

In both NHANES I and III, the age-adjusted mortality rate among participants who performed spirometry was highest among those with moderate or severe COPD followed by those with restrictive impairment (Table 2). The rate among participants with moderate or severe COPD was about 2.5 to 3 times higher than the rate among participants with normal lung function.

Table Graphic Jump Location
Table 2 —Age-Adjusted All-Cause Mortality Rates for Adults Aged 25 to 74 Years in the United States

See Table 1 legend for expansion of abbreviation.

The age-adjusted mortality rate for each group of participants was lower among NHANES III participants than among NHANES I participants (Table 2). Except for the decreases among participants with respiratory symptoms and with normal lung function, however, none of these decreases was statistically significant as judged by the 95% CI. The relative decrease among participants with moderate or severe COPD was about one-third that of participants with normal lung function. Robust and significant decreases in the age-adjusted mortality rate from diseases of the circulatory system occurred among all groups except those with restrictive impairment (Table 3). For the remaining causes of death, however, decreases in the age-adjusted mortality rate were much smaller; for participants with moderate or severe COPD, a nonsignificant increase was noted (Table 4).

Table Graphic Jump Location
Table 3 —Age-Adjusted Mortality Rates From Diseases of the Circulatory System for Adults Aged 25 to 74 Years in the United States

See Table 1 legend for expansion of abbreviation.

Table Graphic Jump Location
Table 4 —Age-Adjusted Mortality Rates From Noncirculatory Diseases for Adults Aged 25 to 74 Years in the United States

See Table 1 legend for expansion of abbreviation.

With the exception of men with moderate or severe COPD or men with mild COPD, men in the other categories experienced significant decreases in the age-adjusted mortality rate (Fig 2). In contrast, only women with normal lung function showed a significant improvement. Interaction tests between sex and cohort suggested significant sex differences in the incidence density ratio comparing NHANES I and NHANES III participants with moderate or severe COPD (P = .020) and restrictive impairment (P = .087). Among NHANES I participants, men had significantly higher age-adjusted mortality rates than women for each GOLD category. Despite the generally larger absolute decreases in the age-adjusted mortality rates among men than among women, men with COPD in NHANES III still experienced significantly higher mortality rates than did women.

Figure Jump LinkFigure 2. Age-adjusted all-cause mortality rates per 1,000 person-years (95% CI) for men and women aged 25 to 74 years in the United States, by survey and GOLD classification. See Figure 1 legend for expansion of abbrevation.Grahic Jump Location

In general, robust decreases in mortality from diseases of the circulatory system were noted in all GOLD categories among men and women (Table 3). In contrast, the mortality rate from other causes appeared to increase among participants with moderate to severe COPD and women with restrictive impairment (Table 4).

Compared with participants with normal pulmonary function, all other participants in both cohorts had an elevated risk for all-cause mortality, ranging from increases of 46% in participants with respiratory symptoms to 137% in participants with moderate or severe COPD in NHANES I and of 48% in participants with respiratory symptoms to 292% in participants with moderate or severe COPD in NHANES III (Table 5).

Table Graphic Jump Location
Table 5 —Mortality According to GOLD Category Among Adults Aged 25 to 74 Years in the United States

Data are presented as adjusted hazard ratios (95% CI). Adjusted for age; sex; race or ethnicity; educational status; smoking status; systolic BP; total cholesterol; BMI; and history of diabetes, myocardial infarction, and stroke. GOLD = Global Initiative for Chronic Obstructive Lung Disease. See Table 1 legend for expansion of other abbreviation.

The present analyses of two nationally representative cohorts of adults in the United States indicate that among adults with either COPD or with restrictive impairment, the age-adjusted mortality rate improved but not always significantly. However, adults with moderate or severe COPD or with restrictive impairment failed to experience a reduction in mortality similar to that experienced by adults with mild COPD, respiratory symptoms alone, or normal lung function. Furthermore, men with moderate to severe COPD generally experienced a larger relative decrease in mortality than did women.

It is almost inevitable that two prospective studies that recruited participants about 17 years apart would not be conducted identically. However, both cohorts used a similar sampling design, had spirometry, and had lengthy follow-up periods. Some differences warrant mention. First, the methodology used to perform spirometry changed over time, but it is unclear whether these changes influenced our results in a meaningful way. Second, the follow-up of the cohorts differed. Whereas participants of NHANES I were contacted several times during the follow-up period and their vital status was assessed using various methods, including the use of the National Death Index, participants of NHANES III were not contacted, and their vital status was established by using only the National Death Index. We performed a sensitivity analysis to examine the possible impact of the two follow-up approaches by fixing the last date of follow-up for NHANES I participants known to be alive and those who had been lost to follow-up to December 31, 1992, and found mortality rates to be 1.3% to 4.5% lower than what is reported in Table 2. Third, the questions used to identify participants with symptoms differed between the two cohorts. Finally, in both cohorts, the causes of death were obtained from the decedents’ death certificates, which may have led to an incorrect cause of death being assigned to some participants.

Strategies to lower mortality among persons with COPD can be conceptualized along three broad lines: (1) reducing or eliminating the modifiable factors that promote the onset of COPD and progressive disease with sustained exposure (ie, smoking), (2) instituting preventive measures that can reduce or eliminate comorbidities that affect mortality, and (3) optimizing outpatient and inpatient COPD-specific treatments shown to reduce mortality. Smoking is acknowledged as the major cause of COPD.10 Thus, for patients who are smokers, smoking cessation is a critical intervention to reduce morbidity and mortality. Although smoking abstinence rates among persons with COPD are low, the use of pharmacotherapy or the combination of counseling and pharmacotherapy can greatly improve this rate and is cost-effective.11 Persons whose COPD is not attributable to smoking may benefit greatly from removing the offending environmental or occupational exposures.

Persons with COPD are at increased risk of dying of cardiovascular disease12; thus, the control of risk factors for cardiovascular disease is critically important. However, relatively little is known about the risk factor profile for cardiovascular disease among persons with pulmonary disease. In recent years, the potential role of treatment with statins in reducing morbidity and mortality among persons with COPD has drawn substantial interest.13

Because of their compromised lung function, persons with COPD are more susceptible to respiratory infections, such as influenza. Although uncertainty about the benefits of pneumococcal vaccination in this population remains to be addressed,14 evidence shows that influenza vaccination reduces mortality among persons with COPD.15 Compliance with recommendations for vaccinations against influenza and pneumococcal disease is substantial among this population, but more can be achieved.16

The treatment of COPD has evolved as new therapeutic agents have become available, and the cornerstones of current treatment include medications (oral and inhaled corticosteroids, short- and long-acting bronchodilators), oxygen treatment, pulmonary rehabilitation, and disease management.17 Although guidelines for managing patients with COPD reflect the evolution in treatments,18 there is evidence of their incomplete uptake by general practitioners.19 A critical factor in the effectiveness of current treatments in reducing morbidity and mortality in patients with COPD is adherence to treatments.20 Long-term home oxygen treatment also may help to improve the prognosis of patients with COPD with severe hypoxemia.19 Evidence from a few small trials suggests that respiratory rehabilitation reduces mortality.21 Thus far, disease management programs have not shown a benefit in reducing mortality.22

Persons with COPD are susceptible to acute exacerbations of their disease that are primarily caused by infections. Because these exacerbations increase mortality, their prevention and optimal management represent one avenue for reducing mortality from this disease.2325

The present finding that the age-adjusted mortality rate in women declined little compared with men, particularly among those with moderate to severe COPD or with restrictive impairment, suggests that women may be less likely to receive a diagnosis of lung disease and may be less intensively managed than men.26 Other explanations such as differences in the natural history of COPD, responses to treatment, quality of life, and nutritional status also merit consideration.27 For example, women with COPD were shown to have more frequent exacerbations than men.28 Furthermore, differences in the temporal changes in risk factors for mortality, such as smoking, may have contributed to the sex disparity. The generally steeper decline in the prevalence of current smoking among men than among women may have contributed in part to the observed changes in mortality among men and women with COPD. Noteworthy is that the lungs of women appear to be more susceptible to the ravages of smoking than those of men,29 and women with COPD may be more addicted to nicotine than men.30

Restrictive impairment has a heterogeneous etiology. Persons with this spirometric impairment may have various comorbidities, including cardiac conditions, diabetes mellitus, and obesity.31 Thus, the primary intervention for this type of impairment in many individuals may not be respiratory. The high mortality rate and limited improvement in the mortality rate among persons with restrictive impairment attests to the serious nature of this lung disorder. Reducing or eliminating exposure to agents known to cause restrictive impairment may limit progressive lung damage and reduce mortality.

As many as one-fourth of the participants in our analyses had respiratory symptoms in the presence of normal lung function. This group of adults with an uncertain prognosis has remained ill defined. Our analyses suggest that they may be at increased risk of mortality. Further research is needed to clarify the risks for morbidity and mortality and any need for interventions to reduce risk in this group.

The present analyses suggest that the relative change in the all-cause mortality rate among adults with moderate to severe COPD was smaller than that among adults with normal lung function. Consequently, the mortality gap between these groups of adults failed to shrink. Of note was the stagnating all-cause mortality rate among women with moderate to severe COPD. If our results are confirmed, the reasons for the suboptimal change in the mortality rate among patients with COPD will require careful thought to appropriately direct clinical and public health efforts to lower the mortality in these patients. In addition, our findings indicate a need to closely monitor the mortality rate among patients with COPD in the future.

Author contributions: Dr Ford had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Dr Ford: contributed to the study concept and design, acquisition of data, analysis and interpretation of data, statistical analysis, study supervision, drafting of the manuscript, and critical revisions of the manuscript for important intellectual content.

Dr Mannino: contributed to the study concept and design, acquisition of data, analysis and interpretation of data, statistical analysis, study supervision, drafting of the manuscript, and critical revisions of the manuscript for important intellectual content.

Dr Zhao: contributed critical revisions of the manuscript for important intellectual content.

Dr Li: contributed to the statistical analysis and critical revisions of the manuscript for important intellectual content.

Dr Croft: contributed to the statistical analysis; administrative, technical, and material support; and critical revisions of the manuscript for important intellectual content.

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Mannino has received honoraria and consulting fees and served on speaker bureaus for GlaxoSmithKline PLC, Novartis Pharmaceuticals, Pfizer Inc, AstraZeneca PLC, Forest Laboratories Inc, and Creative Educational Concepts. Furthermore, he has received royalties from Up-to-Date. Drs Ford, Zhao, Li, and Croft have reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Other contributions: This work was performed at the Centers for Disease Control and Prevention. The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. The analyses of data in the public domain contained in this manuscript were exempt from human subjects review.

GOLD

Global Initiative for Chronic Obstructive Lung Disease

NHANES

National Health and Nutrition Examination Survey

World Health OrganizationWorld Health Organization The global burden of disease: 2004 update. World Health Organization Web site.http://www.who.int/healthinfo/global_burden_disease/GBD_report_2004update_full.pdf. Accessed January 7, 2011.
 
American Lung AssociationAmerican Lung Association State of lung disease in diverse communities 2010. American Lung Association Web site.http://www.lungusa.org/assets/documents/publications/lung-disease-data/solddc_2010.pdf. Accessed January 7, 2011.
 
National Heart, Lung, and Blood InstituteNational Heart, Lung, and Blood Institute Morbidity & mortality: 2009 chartbook on cardiovascular, lung, and blood diseases. National Heart, Lung, and Blood Institute Web site.http://www.nhlbi.nih.gov/resources/docs/2009_ChartBook.pdf. Accessed January 7, 2011.
 
Mannino DM, Buist AS, Petty TL, Enright PL, Redd SC. Lung function and mortality in the United States: data from the First National Health and Nutrition Examination Survey follow up study. Thorax. 2003;585:388-393 [PubMed] [CrossRef]
 
Mannino DM, Doherty DE, Sonia Buist A. Global Initiative on Obstructive Lung Disease (GOLD) classification of lung disease and mortality: findings from the Atherosclerosis Risk in Communities (ARIC) study. Respir Med. 2006;1001:115-122 [PubMed]
 
Centers for Disease Control and PreventionCenters for Disease Control and Prevention NHEFS linked mortality file. Centers for Disease Control and Prevention Web site.http://www.cdc.gov/nchs/data_access/data_linkage/mortality/nhefs_linkage.htm. Accessed January 7, 2011.
 
Centers for Disease Control and PreventionCenters for Disease Control and Prevention NHANES III linked mortality file. Centers for Disease Control and Prevention Web site.http://www.cdc.gov/nchs/data_access/data_linkage/mortality/nhanes3_linkage.htm. Accessed January 7, 2011.
 
Mannino DM, Ford ES, Redd SC. Obstructive and restrictive lung disease and markers of inflammation: data from the Third National Health and Nutrition Examination. Am J Med. 2003;1149:758-762 [PubMed]
 
Mannino DM, Ford ES, Redd SC. Obstructive and restrictive lung disease and functional limitation: data from the Third National Health and Nutrition Examination. J Intern Med. 2003;2546:540-547 [PubMed]
 
Eisner MD, Anthonisen N, Coultas D, et al; Committee on Nonsmoking COPD, Environmental and Occupational Health Assembly Committee on Nonsmoking COPD, Environmental and Occupational Health Assembly An official American Thoracic Society public policy statement: novel risk factors and the global burden of chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2010;1825:693-718 [PubMed]
 
Hoogendoorn M, Feenstra TL, Hoogenveen RT, Rutten-van Mölken MP. Long-term effectiveness and cost-effectiveness of smoking cessation interventions in patients with COPD. Thorax. 2010;658:711-718 [PubMed]
 
Sidney S, Sorel M, Quesenberry CP Jr, DeLuise C, Lanes S, Eisner MD. COPD and incident cardiovascular disease hospitalizations and mortality: Kaiser Permanente Medical Care Program. Chest. 2005;1284:2068-2075 [PubMed]
 
Dobler CC, Wong KK, Marks GB. Associations between statins and COPD: a systematic review. BMC Pulm Med. 2009;9:32 [PubMed]
 
Schenkein JG, Nahm MH, Dransfield MT. Pneumococcal vaccination for patients with COPD: current practice and future directions. Chest. 2008;1333:767-774 [PubMed]
 
Schembri S, Morant S, Winter JH, MacDonald TM. Influenza but not pneumococcal vaccination protects against all-cause mortality in patients with COPD. Thorax. 2009;647:567-572 [PubMed]
 
Jiménez-García R, Ariñez-Fernandez MC, Hernández-Barrera V, Garcia-Carballo MM, de Miguel AG, Carrasco-Garrido P. Compliance with influenza and pneumococcal vaccination among patients with chronic obstructive pulmonary disease consulting their medical practitioners in Catalonia, Spain. J Infect. 2007;541:65-74 [PubMed]
 
Qaseem A, Snow V, Shekelle P, et al; Clinical Efficacy Assessment Subcommittee of the American College of Physicians Clinical Efficacy Assessment Subcommittee of the American College of Physicians Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2007;1479:633-638 [PubMed]
 
Global Initiative for Chronic Obstructive Lung DiseaseGlobal Initiative for Chronic Obstructive Lung Disease Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Global Initiative for Chronic Obstructive Lung Disease Web site.http://www.goldcopd.org/guidelines-global-strategy-for-diagnosis-management.html. Updated 2010. Accessed November 1, 2011.
 
Cranston JM, Crockett AJ, Moss JR, Alpers JH. Domiciliary oxygen for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2005;4:CD001744
 
Vestbo J, Anderson JA, Calverley PM, et al. Adherence to inhaled therapy, mortality and hospital admission in COPD. Thorax. 2009;6411:939-943 [PubMed]
 
Puhan MA, Scharplatz M, Troosters T, Steurer J. Respiratory rehabilitation after acute exacerbation of COPD may reduce risk for readmission and mortality—a systematic review. Respir Res. 2005;6:54 [PubMed]
 
Peytremann-Bridevaux I, Staeger P, Bridevaux PO, Ghali WA, Burnand B. Effectiveness of chronic obstructive pulmonary disease-management programs: systematic review and meta-analysis. Am J Med. 2008;1215:433-443 [PubMed]
 
Agarwal R, Aggarwal AN, Gupta D, Jindal SK. Inhaled corticosteroids vs placebo for preventing COPD exacerbations: a systematic review and metaregression of randomized controlled trials. Chest. 2010;1372:318-325 [PubMed]
 
Walters JA, Gibson PG, Wood-Baker R, Hannay M, Walters EH. Systemic corticosteroids for acute exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2009;1:CD001288
 
Quon BS, Gan WQ, Sin DD. Contemporary management of acute exacerbations of COPD: a systematic review and metaanalysis. Chest. 2008;1333:756-766 [PubMed]
 
Chapman KR, Tashkin DP, Pye DJ. Gender bias in the diagnosis of COPD. Chest. 2001;1196:1691-1695 [PubMed]
 
van Haren-Willems J, Heijdra Y. Increasing evidence for gender differences in chronic obstructive pulmonary disease. Womens Health (Lond Engl). 2010;64:595-600 [PubMed]
 
Hurst JR, Vestbo J, Anzueto A, et al; Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints (ECLIPSE) Investigators Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints (ECLIPSE) Investigators Susceptibility to exacerbation in chronic obstructive pulmonary disease. N Engl J Med. 2010;36312:1128-1138 [PubMed]
 
Sørheim IC, Johannessen A, Gulsvik A, Bakke PS, Silverman EK, DeMeo DL. Gender differences in COPD: are women more susceptible to smoking effects than men? Thorax. 2010;656:480-485 [PubMed]
 
Vozoris NT, Stanbrook MB. Smoking prevalence, behaviours, and cessation among individuals with COPD or asthma. Respir Med. 2011;1053:477-484 [PubMed]
 
Mannino DM, Holguin F, Pavlin BI, Ferdinands JM. Risk factors for prevalence of and mortality related to restriction on spirometry: findings from the First National Health and Nutrition Examination Survey and follow-up. Int J Tuberc Lung Dis. 2005;96:613-621 [PubMed]
 

Figures

Figure Jump LinkFigure 1. Unadjusted distribution of categories of GOLD (Global Initiative for Chronic Obstructive Lung Disease) classification among adults aged 25 to 74 years in the United States, by survey and sex. NHANES = National Health and Nutrition Examination Survey.Grahic Jump Location
Figure Jump LinkFigure 2. Age-adjusted all-cause mortality rates per 1,000 person-years (95% CI) for men and women aged 25 to 74 years in the United States, by survey and GOLD classification. See Figure 1 legend for expansion of abbrevation.Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1 —Unadjusted Means and Percentages for Selected Baseline Characteristics Among Adults Aged 25-74 Years in the United States by GOLD Classification

Data are presented as mean ± SE. To convert total cholesterol from mg/dL to mmol/L, multiply by 0.0259. NHANES = National Health and Nutrition Examination Survey.

a 

Does not meet the standard of statistical reliability and precision (relative SE ≥ 30%).

Table Graphic Jump Location
Table 2 —Age-Adjusted All-Cause Mortality Rates for Adults Aged 25 to 74 Years in the United States

See Table 1 legend for expansion of abbreviation.

Table Graphic Jump Location
Table 3 —Age-Adjusted Mortality Rates From Diseases of the Circulatory System for Adults Aged 25 to 74 Years in the United States

See Table 1 legend for expansion of abbreviation.

Table Graphic Jump Location
Table 4 —Age-Adjusted Mortality Rates From Noncirculatory Diseases for Adults Aged 25 to 74 Years in the United States

See Table 1 legend for expansion of abbreviation.

Table Graphic Jump Location
Table 5 —Mortality According to GOLD Category Among Adults Aged 25 to 74 Years in the United States

Data are presented as adjusted hazard ratios (95% CI). Adjusted for age; sex; race or ethnicity; educational status; smoking status; systolic BP; total cholesterol; BMI; and history of diabetes, myocardial infarction, and stroke. GOLD = Global Initiative for Chronic Obstructive Lung Disease. See Table 1 legend for expansion of other abbreviation.

References

World Health OrganizationWorld Health Organization The global burden of disease: 2004 update. World Health Organization Web site.http://www.who.int/healthinfo/global_burden_disease/GBD_report_2004update_full.pdf. Accessed January 7, 2011.
 
American Lung AssociationAmerican Lung Association State of lung disease in diverse communities 2010. American Lung Association Web site.http://www.lungusa.org/assets/documents/publications/lung-disease-data/solddc_2010.pdf. Accessed January 7, 2011.
 
National Heart, Lung, and Blood InstituteNational Heart, Lung, and Blood Institute Morbidity & mortality: 2009 chartbook on cardiovascular, lung, and blood diseases. National Heart, Lung, and Blood Institute Web site.http://www.nhlbi.nih.gov/resources/docs/2009_ChartBook.pdf. Accessed January 7, 2011.
 
Mannino DM, Buist AS, Petty TL, Enright PL, Redd SC. Lung function and mortality in the United States: data from the First National Health and Nutrition Examination Survey follow up study. Thorax. 2003;585:388-393 [PubMed] [CrossRef]
 
Mannino DM, Doherty DE, Sonia Buist A. Global Initiative on Obstructive Lung Disease (GOLD) classification of lung disease and mortality: findings from the Atherosclerosis Risk in Communities (ARIC) study. Respir Med. 2006;1001:115-122 [PubMed]
 
Centers for Disease Control and PreventionCenters for Disease Control and Prevention NHEFS linked mortality file. Centers for Disease Control and Prevention Web site.http://www.cdc.gov/nchs/data_access/data_linkage/mortality/nhefs_linkage.htm. Accessed January 7, 2011.
 
Centers for Disease Control and PreventionCenters for Disease Control and Prevention NHANES III linked mortality file. Centers for Disease Control and Prevention Web site.http://www.cdc.gov/nchs/data_access/data_linkage/mortality/nhanes3_linkage.htm. Accessed January 7, 2011.
 
Mannino DM, Ford ES, Redd SC. Obstructive and restrictive lung disease and markers of inflammation: data from the Third National Health and Nutrition Examination. Am J Med. 2003;1149:758-762 [PubMed]
 
Mannino DM, Ford ES, Redd SC. Obstructive and restrictive lung disease and functional limitation: data from the Third National Health and Nutrition Examination. J Intern Med. 2003;2546:540-547 [PubMed]
 
Eisner MD, Anthonisen N, Coultas D, et al; Committee on Nonsmoking COPD, Environmental and Occupational Health Assembly Committee on Nonsmoking COPD, Environmental and Occupational Health Assembly An official American Thoracic Society public policy statement: novel risk factors and the global burden of chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2010;1825:693-718 [PubMed]
 
Hoogendoorn M, Feenstra TL, Hoogenveen RT, Rutten-van Mölken MP. Long-term effectiveness and cost-effectiveness of smoking cessation interventions in patients with COPD. Thorax. 2010;658:711-718 [PubMed]
 
Sidney S, Sorel M, Quesenberry CP Jr, DeLuise C, Lanes S, Eisner MD. COPD and incident cardiovascular disease hospitalizations and mortality: Kaiser Permanente Medical Care Program. Chest. 2005;1284:2068-2075 [PubMed]
 
Dobler CC, Wong KK, Marks GB. Associations between statins and COPD: a systematic review. BMC Pulm Med. 2009;9:32 [PubMed]
 
Schenkein JG, Nahm MH, Dransfield MT. Pneumococcal vaccination for patients with COPD: current practice and future directions. Chest. 2008;1333:767-774 [PubMed]
 
Schembri S, Morant S, Winter JH, MacDonald TM. Influenza but not pneumococcal vaccination protects against all-cause mortality in patients with COPD. Thorax. 2009;647:567-572 [PubMed]
 
Jiménez-García R, Ariñez-Fernandez MC, Hernández-Barrera V, Garcia-Carballo MM, de Miguel AG, Carrasco-Garrido P. Compliance with influenza and pneumococcal vaccination among patients with chronic obstructive pulmonary disease consulting their medical practitioners in Catalonia, Spain. J Infect. 2007;541:65-74 [PubMed]
 
Qaseem A, Snow V, Shekelle P, et al; Clinical Efficacy Assessment Subcommittee of the American College of Physicians Clinical Efficacy Assessment Subcommittee of the American College of Physicians Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2007;1479:633-638 [PubMed]
 
Global Initiative for Chronic Obstructive Lung DiseaseGlobal Initiative for Chronic Obstructive Lung Disease Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Global Initiative for Chronic Obstructive Lung Disease Web site.http://www.goldcopd.org/guidelines-global-strategy-for-diagnosis-management.html. Updated 2010. Accessed November 1, 2011.
 
Cranston JM, Crockett AJ, Moss JR, Alpers JH. Domiciliary oxygen for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2005;4:CD001744
 
Vestbo J, Anderson JA, Calverley PM, et al. Adherence to inhaled therapy, mortality and hospital admission in COPD. Thorax. 2009;6411:939-943 [PubMed]
 
Puhan MA, Scharplatz M, Troosters T, Steurer J. Respiratory rehabilitation after acute exacerbation of COPD may reduce risk for readmission and mortality—a systematic review. Respir Res. 2005;6:54 [PubMed]
 
Peytremann-Bridevaux I, Staeger P, Bridevaux PO, Ghali WA, Burnand B. Effectiveness of chronic obstructive pulmonary disease-management programs: systematic review and meta-analysis. Am J Med. 2008;1215:433-443 [PubMed]
 
Agarwal R, Aggarwal AN, Gupta D, Jindal SK. Inhaled corticosteroids vs placebo for preventing COPD exacerbations: a systematic review and metaregression of randomized controlled trials. Chest. 2010;1372:318-325 [PubMed]
 
Walters JA, Gibson PG, Wood-Baker R, Hannay M, Walters EH. Systemic corticosteroids for acute exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2009;1:CD001288
 
Quon BS, Gan WQ, Sin DD. Contemporary management of acute exacerbations of COPD: a systematic review and metaanalysis. Chest. 2008;1333:756-766 [PubMed]
 
Chapman KR, Tashkin DP, Pye DJ. Gender bias in the diagnosis of COPD. Chest. 2001;1196:1691-1695 [PubMed]
 
van Haren-Willems J, Heijdra Y. Increasing evidence for gender differences in chronic obstructive pulmonary disease. Womens Health (Lond Engl). 2010;64:595-600 [PubMed]
 
Hurst JR, Vestbo J, Anzueto A, et al; Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints (ECLIPSE) Investigators Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints (ECLIPSE) Investigators Susceptibility to exacerbation in chronic obstructive pulmonary disease. N Engl J Med. 2010;36312:1128-1138 [PubMed]
 
Sørheim IC, Johannessen A, Gulsvik A, Bakke PS, Silverman EK, DeMeo DL. Gender differences in COPD: are women more susceptible to smoking effects than men? Thorax. 2010;656:480-485 [PubMed]
 
Vozoris NT, Stanbrook MB. Smoking prevalence, behaviours, and cessation among individuals with COPD or asthma. Respir Med. 2011;1053:477-484 [PubMed]
 
Mannino DM, Holguin F, Pavlin BI, Ferdinands JM. Risk factors for prevalence of and mortality related to restriction on spirometry: findings from the First National Health and Nutrition Examination Survey and follow-up. Int J Tuberc Lung Dis. 2005;96:613-621 [PubMed]
 
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