COPD in Los Angeles County: A Call to Action

1. COPD in Los Angeles County: A Call to Action Jonathan Fielding, MD, MPH, MA, MBA Director and Health Officer Los Angeles County Department of Public Health November 20, 2013

2. Vision: Healthy People in Healthy Communities Mission: To protect health, prevent disease, and promotehealth and well-being Departmental Stats: Annual budget over $850 million Nearly 4,000 employees Los Angeles CountyDepartment of Public Health

3. How Many Persons in Los Angeles 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.

4. Trends in the Leading Causes of Death Los Angeles County, 2001-2010 Source: Office of Health Assessment and Epidemiology, Los Angeles County Department of Public Health

5. COPD Mortalityby Gender and Race/Ethnicity, Los Angeles County, 2010 Source: California DPH Death Statistical Master File for Los Angeles County Residents, 2010

6. COPD Mortality by Service Planning Area Los Angeles County, 2010 Source: California DPH Death Statistical Master File for Los Angeles County Residents, 2010

7. Risk Factors for COPD • Smoking and second-hand smoke exposure (the major preventable cause) • Exposure to air pollutants (ambient, workplace, home) • Genetic factors • Respiratory infections • Other?

8. California a Leader in Tobacco Control • 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

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

10. Prevalence of Cigarette Smoking Among Adults (18 years and older), Los Angeles County, 1997-2011 • prevalence based on current use of cigarettes • prevalence based on current use of cigarettes and having smoked 100 lifetime cigarettes • Sample includes cell phone users Source: LA County Health Survey

11. Percentage of Adult Cigarette Smokers by Gender and Race/Ethnicity Los Angeles County, 2011 *The estimate is statistically unstable (relative standard error >23%) Source: Los Angeles County Health Survey, Department of Public Health

12. Smoking 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.

13. Trends in COPD Mortality1979-2010 Source: CDC, National Center for Health Statistics

14. Trends in Lung Cancer Mortality1979-2010 Source: CDC, National Center for Health Statistics

15. Health Impacts of Air Pollution in Southern California (per year) Data Source: South Coast Air Quality Management District, 2010, http://www.aqmd.gov/ej/CAC/health_impacts.htm

16. Ozone Trends: Los Angeles County Source: http://www.arb.ca.gov/adam/trends/trends1.php

17. PM 2.5 Trends: Los Angeles County Source: http://www.arb.ca.gov/adam/trends/trends1.php

18. Reducing 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.")

19. Broader 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

20. Opportunities 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

21. Prevention Opportunities from Community 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 materials

22. Several 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.

23. Additional Potential Benefits of ACA for Persons 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

24. Major 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