Lung (2015) 193:53–62 DOI 10.1007/s00408-014-9682-6
COPD
Trends in Self-Rated Health Status and Health Services Use in COPD Patients (2006–2012). A Spanish Population-Based Survey Javier de Miguel Dı´ez • Rodrigo Jime´nez Garcı´a • Valentı´n Herna´ndez Barrera • Luis Puente Maestu • Maria Isabel del Cura Gonza´lez • Manuel Me´ndez Bailo´n • Pilar Carrasco Garrido • Ana Lo´pez de Andre´s
Received: 15 November 2014 / Accepted: 21 December 2014 / Published online: 31 December 2014 Ó Springer Science+Business Media New York 2014
Abstract Background Chronic obstructive pulmonary disease (COPD) patients often have a significant impairment in their health status, which is an independent predictor of health services use. Objectives To describe the self-rated health status and the prevalence of health services use among COPD Spanish patients; to identify which factors are independently associated with a worse health status and a higher use of health services; and to study the time trends in the health status and prevalence of use of health services (2006–2012). Methods Observational study: We analyzed data from the Spanish National Health Surveys conducted in 2006 and 2012. We included responses from adults aged 40 years or over. Subjects described their health status as very good, good, fair, poor, or very poor, which was dichotomized into
J. de Miguel Dı´ez (&) L. Puente Maestu Department of Respiratory Medicine, Hospital General Universitario Gregorio Maran˜o´n, Instituto de Investigacio´n Sanitaria Gregorio Maran˜o´n (IiSGM), Universidad Complutense de Madrid, C/Doctor Esquerdo 46, 28007 Madrid, Spain e-mail: [email protected] R. Jime´nez Garcı´a V. Herna´ndez Barrera P. Carrasco Garrido A. Lo´pez de Andre´s Preventive Medicine and Public Health Teaching and Research Unit, Department of Health Sciences, Universidad Rey Juan Carlos, Madrid, Spain M. I. del Cura Gonza´lez Unit of Research Support, Technical Direction for Teaching and Research, Attached Management of Planning and Quality, Madrid, Spain M. Me´ndez Bailo´n Department of Internal Medicine, Hospital Clı´nico San Carlos, Madrid, Spain
very good/good or fair/poor/very poor self-perceived health status. Results We identified 2,321 COPD patients. The percentage of patients with health status fair, poor, or very poor was 76.8 % in 2006 and 74.8 % in 2012 (p [ 0.05). Regarding the health resources use, we observed a significant decrease in the number of visits to primary care over time in women (67.8 vs. 57.2 %, p \ 0.05) and men (62.2 vs. 54.0 %, p \ 0.05). However, we did not find improvement in the prevalence of emergency department visits or hospitalizations. Associated factors with a worse self-rated health status and a higher use of health services in women and men included: having three or more chronic diseases, presence of mental disorders, and absence of leisure time physical activity. Conclusions The current study revealed a decrease in the general practitioner visits, without changes in use of other health care services in the COPD Spanish population from 2006 to 2012. The self-rated health status did not changed significantly during this period. Keywords COPD Health status Health services Population-based
Introduction Chronic obstructive pulmonary disease (COPD), including emphysema and chronic bronchitis, is a common disorder characterized by persistent airflow limitation that is usually progressive [1]. Latest estimations in Spain, using the GOLD criteria, set COPD prevalence in 10.2 % in individuals between 40 and 80 years of age [2]. It is an important cause of morbidity and mortality worldwide and, by 2030, is expected to be the third leading cause of death
123
54
and rank seventh as burden of disease [3, 4]. Individuals with COPD may experience disabling respiratory symptoms and they often suffer comorbid conditions [5]. Consequently, these patients often have a significant impairment in their health status [6], which is an independent predictor of health services use and place significant burden on health care systems and society [7, 8]. Current governments are confronted with managing resources in the face of an economic recession [9]. Since patients with COPD are frequent users of health resources, one better understanding of the patterns of use of these services is fundamental for the establishment of health plans geared toward the proper management of COPD and the reduction of overall costs of this disease. However, data about COPD-related health care are lacking [10]. Health status assessment has also been suggested a possible performance measure in evaluation system of care [11]. Administrative data provide a practical way of capturing health services use. It is particularly helpful when it comes from universal, single-payer health care insurance that captures all encounters from a complete real-world population with minimal bias due to financial barriers to care. Following this methodology, Gershan et al. have recently found that individuals with COPD use large and disproportionate amounts of health services, being responsible for up to one-third of all hospitalizations, emergency department visits, ambulatory care visits, long-term care resident places, and home care use in the province of Ontario, Canada [8]. However, it has been demonstrated the existence of geographical variations in medical care so the results cannot be extrapolated to other countries [11, 12]. The Spanish system provides universal health care coverage, with limitations regarding mental, pharmacological, and dental services. In fact, access from primary to specialized (higher) health care levels is determined by first level physician diagnosis [13]. No previous study has determined time trends of use of health care services in people with COPD the last years in Spain. Therefore, this study sought to estimate the self-reported health status and the prevalence of the use of health care services among Spanish COPD patients, associated factors and time trends, using two Spanish National Health Surveys conducted from 2006 to 2012 with particular attention to gender differences. The main objectives of this study were (1) to describe the self-rated health status and the prevalence of general medical practitioner visits within the last 4 weeks and emergency department visits and hospitalizations in the last year according to sex and age groups; (2) to identify which factors, including socio-demographic characteristics, health-related and lifestyle variables, were independently associated to a worse self-rated health status and the higher use of health care services among COPD Spanish patients,
123
Lung (2015) 193:53–62
women and men; and (3) to study the time trends in the self-rated health status and in the prevalence of the use of health care services over the period 2006–2012.
Methods Study Design and Population A repeated cross-sectional study was conducted using individualized data drawn from two National Health Surveys conducted in Spain in the years 2006 (n = 29,478) and 2012 (n = 21,007). These surveys were performed by the Ministry of Health and Consumer Affairs and the National Statistics Institute (Instituto Nacional de Estadı´stica—INE). The national survey is an ongoing, home-based personal interview examining a national representative sample of non-institutionalized population residing in main family dwellings (households) of Spain. It uses a multistage cluster sampling with proportional random selection of primary and secondary sampling units (towns and sections, respectively), with the final units (individuals) being selected by means of random routes and sex- and age-based quotas. All the surveys included provide a representative sample for the Spanish non-institutionalized population residing in main family dwellings (households). Surveyors were previously trained about basic communication skills, procedure, and the questionnaire. More details of the survey methodologies are described elsewhere [14, 15]. For study purposes of the current study, subjects aged 40 years or over were selected from the NHS 2006 (n = 20,060) and NHS 2012 (n = 14,584). We identified individuals suffering COPD as those that answered ‘‘yes’’ to the question ‘‘has your doctor told you that you are currently suffering from chronic bronchitis, emphysema, or COPD?’’ The variables included in the current study were created on the basis of a series of questions identically worded in the questionnaires and identical in the two surveys. The questions used to assess the use of health care services were (1) have you been admitted to a hospital for at least one night in the preceding year?; (2) have you visited an emergency department for any medical situation in the last year?; (3) have you visited a general physician for any medical situation in the last 4 weeks? Independent variables included socio-demographic characteristics such as age (40–54, 55–69 and 70 years or older), gender, nationality (immigrant or Spanish), size of town (\50,000 or C50,000 inhabitants), educational level (no studies, primary or secondary education completed), social class (it was defined using information from monthly income: low \850 €, medium 850–1,400 €, or high [1,400 €), living with a partner (yes/no), occupancy
Lung (2015) 193:53–62
55
(working or non-working), smoking habit (current smokers, ex-smokers or non-smokers), and body mass index (BMI, calculated from self-reported body weight and height). Individuals with a BMI C30 were classified as obese. Further, physical exercise habits applied to cases where subjects acknowledged doing no physical activity in their leisure time. Self-rated health status was assessed with the following question: ‘‘How do you self-rate your health status over the previous 12 months?’’ Subjects described their health status as very good, good, fair, poor, very poor. The answer was dichotomized into very good/good or fair/poor/very poor perceived health status. We also collected the number of medical diagnoses of comorbid chronic conditions including diabetes, high blood pressure, asthma, heart disease, myocardial infarction, cancer, arthritis, and stroke. To identify individuals with associated chronic conditions, we used self-reported affirmative answer to the presence of any physician diagnosed concomitant diseases. The number of medical diagnoses was categorized as none, one or two, and three or more. Finally, information regarding mental disorders (depression and/or anxiety) was obtained from the questionnaires. The presence of mental disease was assessed using the following questions: (1) ‘‘has your doctor told you that you are currently suffering from depression?’’, and (2) has your doctor told you that you are currently suffering from anxiety?’’. Those who answered yes to questions 1 and/or 2 were classified as mental disease sufferers.
variables for the multivariate analysis. We included all the variables whose bivariate tests were significant and those we considered scientifically relevant according to the references reviewed; (3) in order to fit the multivariate model the importance of each variable included in the model was verified. This included the examination of the Wald statistic for each variable and comparison of each estimated coefficient with the coefficient from the bivariate model containing only that variable; and (4) once the model was obtained, we looked more closely at the variables included (linearity) and checked for interactions in the model. The results of the logistic regression models are reported as adjusted odds ratios (ORs) with their 95 % confidence intervals. The estimates were made using the ‘‘svy’’ (survey command) functions of the STATA program (StataCorp LP, Lakeway Drive, College Station, TX, USA), which allowed us to incorporate the study design and weights in all our statistical calculations. Statistical significance was established at p \ 0.05 (two-tailed p values).
Statistical Analysis
Results
All data analyses were performed separately for women and men. First, we estimated the distribution of the sample according to the study variables for each National Health Survey. Second, we calculated and compared the prevalence self-rated health and use of health care service variables according to age groups in each of the two surveys. To perform bivariate comparisons, we used the Chisquare test for trend statistics for categorical variables and two-sided independent t tests for continuous variables. Third, for each dependent variable (self-rated health, general practitioner visit, utilization of the emergency department, and hospitalizations), we then fitted multivariate logistic regression models. With these models, we identified those study variables independently associated with the perception and the use of health care services and assessed the time trend from 2006 to 2012. The logistic regression multivariate model was conducted joining the databases for the two health surveys, NHS 2006 and NHS 2012. It was created using the ‘‘enter modeling’’ method. The process included four steps: (1) bivariate analysis of each variable; (2) selection of the
The total number of subjects with COPD included in the study was 2,321 (2006: n = 1,320; 2012: n = 1,001). The prevalence of COPD in NHS 2006 and NHS 2012 was 6.58 % (95 % CI 6.24–6.92), and 6.86 % (95 % CI 6.45–7.27), respectively. Table 1 shows the distribution, according to age and sex, of the variables included in the study. Overall, we did not find differences in self-rated health of patients with COPD between 2006 and 2012. Thus, the percentage of patients with fair, poor, or very poor perceived health status was 76.8 % in 2006 and 74.8 % in 2012 (p [ 0.05). Furthermore, after adjusting for possible confounders the time trend remained not significant (adjusted OR 1.13, 95 % CI 0.73–1.75). Regarding the health resources use, we observed a significant decrease in the number of visits to primary care over time (64.7 vs. 55.5 %), in both women (67.8 vs. 57.2 %) and men (62.2 vs. 54.0 %). In contrast, we did not find improvement in the percentage of emergency department visits (45.5 vs. 46.6 %) or hospitalizations (22.6 vs. 20.4 %). Tables 2 and 3 show the distribution of the self-rated health and the health resources use according the study
Ethical Aspects As this analysis was conducted on de-identified, public-use datasets, it was not necessary to have the approval of an ethics committee according to Spanish legislation. The participants gave their written informed consent to participate in the surveys and also that the results were published.
123
56
Lung (2015) 193:53–62
Table 1 Distribution, according to age and sex, of the variables included in the Spanish National Health Surveys (NHS) conducted in 2006 and 2012 Variables
Women
Men
Total
Categories
Self-rated health fair/poor/ very poor n (%)
General practitioner visit last 4 weeks n (%)
Hospitalizationlast 12 months n (%)
Emergengy department visit last 12 months n (%)
NHS 2006
NHS 2006
NHS 2012
NHS 2006
NHS 2012
NHS 2006
NHS 2012
99 (57.9)
19 (11.9)
18 (10.4)
74 (45.7)
89 (52.3)
33 (15.4)
32 (13.6)
90 (42.5)
90 (38.7)
NHS 2012
Age (years) 40–54
100 (61.3)
97 (57.2)
98 (60.5)
55–69
176 (82.9)*
163 (70.2)
154 (72.3)*
125 (54)
70 or more
242 (90.9)
274 (87.5)
183 (68.7)
185 (59.2)
64 (20.5)
133 (50.1)
175 (55.8)
Total
518 (80.8)
534 (74.7)
435 (67.8)*
409 (57.2)
134 (20.9)
114 (15.9)
298 (46.5)
353 (49.4)
82 (30.9)*
Age (years) 40–54
76 (62.4)
58 (47.6)
57 (41)
21 (17.4)
21 (15.3)
50 (41)
55–69
205 (70.6)
209 (72)
91 (65.5)
172 (59.3)*
140 (48.2)
56 (19.2)
57 (19.6)
131 (45.3)
69 (49.8)
70 or more
278 (79.7)
316 (80.3)
243 (69.7)
247 (62.8)
105 (30.1)
122 (30.9)
158 (45.3)
184 (46.6)
Total
558 (73.5)
616 (74.8)
472 (62.2)*
444 (54)
182 (23.9)
200 (24.3)
339 (44.6)
363 (44.1)
175 (61.8)
188 (60.9)
156 (55)
155 (50.3)
40 (14.2)
39 (12.6)
124 (43.7)
158 (51.2)
381 (75.8)
371 (71.2)
325 (64.8)*
265 (50.8)
88 (17.6)
88 (17)
221 (44.1)
200 (38.3)
520 (84.6) 1,076 (76.8)
590 (83.5) 1,149 (74.8)
426 (69.2)* 907 (64.7)*
433 (61.2) 853 (55.5)
187 (30.5) 316 (22.6)
186 (26.3) 313 (20.4)
291 (47.4) 637 (45.5)
358 (50.7) 716 (46.6)
110 (38)
Age (years) 40–54 55–69 70 or more Total
* Significant association between study variables and Spanish National Health Survey
variables, in the two national surveys conducted in Spain between 2006 and 2012, in men and women, respectively. When comparing the results of the two surveys, we found a worsening of self-rated health status in patients with three or more chronic diseases in men and in patients with three or more chronic diseases in women. Additionally, in women, we observed a decrease in this variable over time, in those with active work, in those who consumed alcohol and those who did not practice physical activity in their free time. Regarding the health resources use, the most consistent improvements occurred in relation to visits to primary care, especially among women. Table 4 shows the variables that were significantly associated with a worse self- rated health status, and with a higher use of health care services among Spanish women and men, with the adjusted OR and their corresponding 95 % confidence intervals. Associated factors with a worse self-rated health in both, women and men, were lowest educational level, having three or more chronic diseases, suffering mental disorders, and not practice of leisure time physical activity. In addition, older age was also associated with a worse self-rated health in women, but not in men. In relation to the health resources use, having three or more chronic diseases was associated with a higher probability of general practitioner visits (OR 2.02, 95 % CI 1.14–3.57 in women; OR 1.75, 95 % CI 1.03–2.95 in men), emergency department visits (OR 1.87, 95 % CI 1.14–3.09 in women; OR 2.45, 95 % CI 1.43–4.19 in men), and hospitalizations (OR 5.04, 95 % CI 2.21–11.48 in women;
123
OR 3.06, 95 % CI 1.70–5.50 in men) in women and men. Additionally, the presence of mental disorders and the absence of practice of leisure time physical activity were variables associated with a lower probability of emergency department visits and hospitalization, respectively, in both gender. Other factors related to health resources utilization in women were being married and having a lower social class, which were associated with a higher probability of visits to the general practitioner (Table 4). For men, a higher age was associated with a higher probability of general practitioner visits, but neither to emergency room visits nor hospitalizations. Moreover, women and men that were not drinkers had a higher probability of general practitioner visits (Table 4). Finally, the multivariate analysis, showed that the time trend of the number of visits to the general practitioner significantly decreased in women and men from 2006 to 2012. However, no significant variations for emergency department visits or hospitalizations were observed in either women or men. Furthermore, we did not find significant changes in the state of self-rated health during that period, neither in women or men (Table 4).
Discussion The nationally representative data of the current study reveals a high use of health care services in the Spanish COPD population, although we have observed a decrease
Lung (2015) 193:53–62
57
Table 2 Distribution of the self-rated health ‘‘fair/poor/very poor’’ and the health resources use according the study variables, in the two National Health Surveys (NHS) conducted in Spain between 2006 and 2012, in women Women
Self-rated health ‘‘fair/ poor/very poor’’ n (%)
General practitioner visit last 4 weeks n (%)
Hospitalization last 12 months n (%)
Emergency department visit last 12 months n (%)
NHS 2006
NHS 2006
NHS 2006
NHS 2006
NHS 2012
NFS 2012
NHS 2012
NHS 2012
Living with a partner No
238 (87.1)
269 (81.9)
171 (62.8)
184 (56)
66 (24.1)
52 (16.0)
140 (51.3)
178 (54.2)
Yes
278 (76)
264 (68.5)
262 (71.3)*
225 (58.3)
68 (18.6)
61 (15.8)
158 (43.1)
175 (45.4)
Nationality Immigrant
5 (25.7)
16 (46.8)
0 (0)
3 (9.2)
8 (37.1)
11 (31.1)
504 (81.5)*
511 (75)
427 (69.1)*
393 (57.7)
134 (21.7)
110 (16.2)
290 (46.9)
343 (50.4)
\50,000
274 (84)
268 (77.9)
231 (70.8)*
203 (59)
74 (22.8)
68 (19.8)
155 (47.4)
160 (46.6)
C50,000
207 (78.1)
265 (71.7)
176 (66.6)*
206 (55.6)
49 (18.6)
45 (12.3)
118 (44.5)
193 (52.1)
Spanish
12 (58.3)
23 (67.5)
Town size (inhabitants)
Educational level Secundary or more Primary
68 (63)
61 (47.8)
61 (56.2)
66 (51.9)
14 (13)
10 (8.2)
43 (39.8)
50 (38.8)
444 (84.2)
473 (80.6)
368 (69.8)*
343 (58.4)
116 (21.9)
103 (17.6)
250 (47.5)
304 (51.8)
130 (77.7) 294 (81.5)
201 (74.4) 325 (75.4)
100 (59.8) 257 (71.5)*
144 (53.2) 258 (59.8)
36 (21.2) 66 (18.4)
43 (16) 70 (16.3)
71 (42.5) 169 (47)
138 (50.9) 211 (48.9)
Social class High–medium Low Occupation Working Not working
65 (52.1)
75 (64.8)*
53 (43)
12 (10.4)
450 (85.5)*
68 (59)
469 (79.4)
360 (68.5)*
356 (60.2)
122 (23.2)
11 (9)
31 (44.6)
151 (54.1)
37 (53.3)
135 (48.4)
7 (10.6)
14 (5.1)
25 (36.6)
111 (39.8)
286 (84.5)
257 (66.9)
211 (62.4)
66 (17.1)
69 (20.3)
167 (43.5)*
187 (55.4)
63 (64.7)
61 (32.6)
31 (31.5)
105 (56.2)
55 (56.2)
102 (17.3)
47 (41.2)
43 (34.8)
251 (47.6)
310 (52.5)
Number of chronic condition None 1–2
311 (81)
3 or more
176 (93.7)*
97 (99.5)
No
242 (71.5)
262 (65.1)
214 (63.3)*
215 (53.5)
72 (21.4)
59 (14.6)
132 (39.2)
172 (42.6)
Yes
276 (91)
271 (87)
221 (72.8)*
193 (62.1)
62 (20.4)
55 (17.6)
166 (54.5)
182 (58.2) 68 (45.1)
141 (75)
Mental disorders
Smoker Smoker
72 (62.1)
87 (57.4)
68 (58.1)
76 (50.3)
15 (13.3)*
7 (4.3)
54 (46.6)
Ex-smoker
46 (70.3)
45 (54.4)
40 (62)
40 (48.8)
15 (22.4)
13 (15.9)
17 (25.7)
32 (39.2)
Non-smoker Drinker
400 (86.9)
402 (83.6)
327 (71.1)*
292 (60.8)
104 (22.6)
94 (19.5)
227 (49.3)
253 (52.6)
No
386 (84.7)
413 (81.8)
318 (69.9)
311 (61.6)
105 (23)
94 (18.6)
218 (47.9)
245 (48.6)
Yes
132 (71)*
121 (57.6)
116 (62.7)*
98 (46.6)
29 (15.7)
20 (9.4)
80 (43)
108 (51.5)
No
278 (84.4)
345 (84.8)
218 (66.3)
245 (60.2)
86 (26.1)
82 (20.3)
174 (53)
209 (51.4)
Yes
240 (76.9)*
189 (61.3)
217 (69.4)*
164 (53.2)
48 (15.5)
31 (10.1)
124 (39.6)
144 (46.8)
Physical exercise
BMI \30
268 (75.6)
250 (67.0)
224 (63.2)
199 (53.2)
66 (18.6)*
43 (11.5)
157 (44.3)
170 (45.5)
C30
142 (89.6)
207 (83.8)
115 (72.5)
150 (60.5)
32 (20.5)
50 (20.2)
79 (50.2)
131 (52.8)
* Significant association between study variables and Spanish National Health Survey
in the general practitioner visits in the last month. However, there have been not variations in the use of other health care services, such as emergency department visits or hospitalizations. The reduction in the number of visits to primary care is relevant since in the Spanish National
Health Service the primary care is the first step in the health assistance. We believe that a better management of the COPD patients at this level, including an earlier diagnosis and improved therapies, are the reasons for the lower number of visits. We also think that possibly in the next
123
58
Lung (2015) 193:53–62
Table 3 Distribution of the self-rated health and the health resources use according the study variables, in the two National Health Surveys (NHS) conducted in Spain between 2006 and 2012, in men Men
Self-rated health ‘‘fair/ poor/very poor’’ n (%)
General practitioner visits last 4 weeks n (%)
Hospitalization last 12 months n (%)
Emergency department visit last 12 months n (%)
NHS 2006
NHS 2006
NHS 2006
NHS 2006
NHS 2012
NFS 2012
NHS 2012
NHS 2012
Living with a partner No
140 (69.8)
152 (69.6)
122 (60.8)
106 (48.6)
Yes
414 (75)
464 (76.8)
347 (62.7)
338 (55.9)
49 (24.5) 133 (24)
46 (21.1)
79 (39.5)
98 (44.8)
154 (25.4)
253 (45.8)
265 (43.9)
Nationality Immigrant
7 (100)
22 (56.3)
3 (39.8)
24 (59.2)
1 (12.8)
7 (18.4)
6 (82.8)
12 (30.5)
551 (74.1)
593 (75.8)
463 (62.3)*
420 (53.7)
181 (24.3)
192 (24.6)
330 (44.4)
351 (44.8)
\50,000
303 (73.6)
281 (76.7)
260 (63.1)
206 (56.1)
81 (19.6)
98 (26.8)
169 (41)
173 (47.3)
C50,000
196 (74.5)
335 (73.4)
164 (62.3)
238 (52.3)
66 (25.2)
102 (22.3)
119 (45.3)
190 (41.5)
Spanish Town size (inhabitants)
Educational level Secundary or more Primary
86 (61.5)
101 (57.9)
87 (62.3)
84 (48.3)
33 (23.8)
32 (18.3)
54 (39)
63 (35.9)
470 (76.8)
514 (79.4)
380 (62.1)
359 (55.5)
146 (23.9)
168 (25.9)
282 (46)
300 (46.4)
174 (66.3) 377 (77.4)
219 (73.7) 378 (75.2)
177 (67.5)* 289 (59.4)
152 (51.1) 281 (56)
69 (26.3) 110 (22.7)
74 (24.7) 118 (23.5)
105 (39.8) 228 (46.9)
145 (48.8) 207 (41.2)
Social class High–medium Low Occupation Working
107 (62.8)
78 (59.7)
81 (47.6)
51 (39)
31 (17.9)
Not working
451 (76.6)
538 (77.7)
391 (66.4)*
393 (56.8)
151 (25.7)
20 (15.3) 180 (26)
72 (42.3)
40 (30.4)
267 (45.3)
323 (46.7)
Number of chronic condition None
93 (57.6)
248 (63.7)
77 (47.7)
175 (44.9)
24 (14.7)
54 (13.9)
68 (42.2)
136 (34.8)
1–2
310 (74.7)*
294 (83.3)
263 (63.4)
227 (64.3)
94 (22.6)*
115 (32.6)
160 (38.6)*
179 (50.9)
3 or more
155 (84.8)
74 (91.7)
132 (72.2)*
42 (52.5)
64 (35.2)
31 (38.1)
111 (60.5)
48 (59.7)
150 (24.9)
131 (20.5)
271 (44.8)
246 (38.4)
68 (37.7)
67 (43.9)
117 (64.5)
Mental disorders No
424 (70)
459 (71.6)
372 (61.4)*
336 (52.3)
Yes
134 (87.1)
157 (86.5)
100 (65.1)
108 (59.7)
31 (20.3)*
Smoker Smoker
144 (75.3)
143 (65.7)
94 (49.2)
86 (39.3)
Ex-smoker
324 (73.8)
345 (80.2)
288 (65.6)
262 (60.9)
Non-smoker Alcohol drink
90 (69.7)
90 (69.8)
96 (55.1)
127 (73)
20 (10.5) 132 (30)
23 (10.5)
67 (35.2)*
82 (37.8)
133 (30.8)
218 (49.6)
209 (48.6)
30 (23.3)
44 (25.4)
54 (41.8)
71 (40.9)
No
212 (82)
333 (83.2)
177 (68.4)
253 (63.1)
67 (25.8)
111 (27.9)
123 (47.6)
211 (52.6)
Yes
346 (69.1)
283 (66.9)
295 (59)*
191 (45.3)
115 (22.9)
88 (20.9)
216 (43.1)
152 (36.1)
No
257 (77.8)
375 (79.6)
201 (60.7)
266 (56.5)
90 (27.1)
140 (29.7)
163 (49.4)
226 (48)
Yes
301 (70.1)
241 (68.5)
271 (63.3)*
178 (50.6)
92 (21.5)
60 (17)
175 (41)
137 (38.9)
119 (24.2)
116 (22.1)
218 (44.5)
40 (22.3)
52 (23.2)
76 (42)
Physical exercise
BMI \30
365 (74.4)
368 (69.8)
296 (60.3)
274 (52)
C30
130 (72.1)*
188 (84.6)
119 (66)
123 (55.3)
210 (39.8) 111 (50)
* Significant association between study variables and Spanish National Health Survey
years, the improvement in the primary care will also result in a reduction of the emergency department visits or hospitalizations. This study also shows that a high proportion of patients with COPD in Spain have fair, poor, or very poor self-rated
123
health and it has not changed significantly in the last years (76.8 % in 2006 and 74.8 % in 2012). Furthermore, after adjusting for possible confounders the time trend remained not significant (adjusted OR, 1.13 95 % CI 0.73–1.75). This means that even if the use of primary care services has
1 1.13 (0.73–1.75)
2012
1.81 (1.19–2.76)
No
2006
1
NS
Yes
No
NS
Non-smoker 1
NS
Ex-smoker
Yes
1
2.92 (1.85–4.64)
Smoker
Yes
3 or more 1
2.59 (1.62–4.14) 8.74 (4.07–18.76)
1–2
No
1
NS
Low
None
1
1.89 (1.17–3.05)
Primary
High–medium
1
NS
Yes
Secundary or more
1
No
2.59 (1.50–4.48)
70 or more
1
0.69 (0.44–0.97)
1
NS
1
1.52 (1.05–2.18)
1
NS
NS
1
1.45 (1.02–2.05)
1
2.02 (1.14–3.57)
1.57 (1.03–2.40)
1
1.51 (1.07–2.14)
1
NS
1
1.48 (1.04–2.10)
1
0.93 (0.57–1.52)
0.81 (0.51–1.30)
0.90 (0.58–1.40)
1
1.67 (1.11–2.50)
1
NS
1
NS
NS
1
NS
1
5.04 (2.21–11.48)
2.71 (1.28–5.76)
1
NS
1
NS
1
NS
1
1.60 (0.84–3.05)
1.06 (0.54–2.09)
1
1.34 (0.97–1.84)
1
NS
1
NS
1
NS
NS
1
1.75 (1.29–2.37)
1
1.87 (1.14–3.09)
1.48 (0.99–2.21)
1
NS
1
NS
1
NS
1
0.93 (0.61–1.42)
0.60 (0.40–0.91)
1
1.20 (0.80–1.79)
1
1.45 (1.01–2.15)
1
1.96 (1.29–2.97)
1
NS
NS
1
2.20 (1.31–3.69)
1
3.64 (1.69–7.82)
2.17 (1.41–3.31)
1
NS
1
2.09 (1.34–3.27)
1
NS
1
1.14 (0.65–2.03)
0.83 (0.47–1.45)
1
0.73 (0.47–0.96)
1
NS
1
1.61 (1.15–2.26)
1
NS
NS
S
NS
1
1.75 (1.03–2.95)
1.77 (1.22–2.58)
1
NS
1
NS
1
NS
1
1.92 (1.17–3.14)
1.25 (0.76–2.06)
1
GP OR (CI 95 %)
1.23 (0.84–1.82)
1
1.68 (1.17–2.43)
1
NS
1
2.30 (1.23–4.30)
3.12 (1.80–5.30)
1
NS
1
3.06 (1.70–5.50)
2.13 (1.32–3.43)
1
NS
1
NS
1
NS
1
1.08 (0.54–2.14)
0.80 (0.38–1.65)
1
Hospital OR (CI 95 %)
1.11 (0.79–1.56)
1
1.44 (1.05–1.98)
1
NS
1
1.19 (0.73–1.95)
1.69 (1.10–2.57)
1
1.52 (1.04–2.22)
1
2.45 (1.43–4.19)
1.37 (0.92–2.04)
1
NS
1
NS
1
NS
1
0.68 (0.40–1.12)
0.65 (0.39–1.10)
1
ED OR (CI 95 %)
NS not significant, SRH self-rated health fair/poor/very poor, GP general practitioner visit last 4 weeks, Hospital hospitalization last 12 months, ED emergency department visit last 12 months
ENS
Physical exercise
Alcohol drink
Smoker
Mental disorders
Number of chronic conditions
Social class
Educational level
Living with a partner
1 1.72 (1.04–2.84)
40–54
Age groups (years)
ED OR (CI 95 %)
SRH OR (CI 95 %)
Hospital OR (CI 95 %)
SRH OR (CI 95 %)
GP OR (CI 95 %)
Men
Women
55–69
Categories
Variables
Table 4 Adjusted OR for self- rated health and health care services among Spanish COPD patients, women and men, included in the Spanish National Health Surveys (NHS) conducted in 2006 and 2012 (the multivariate model was conducted joining the databases for the two health surveys, NHS 2006 and NHS 2012)
Lung (2015) 193:53–62 59
123
60
decreased over the study period, the patients suffering COPD have not improved their self-rated health so it is necessary to continue searching for strategies to raise the quality of life for these patients. Our study also demonstrates that there are only few differences in the self-reported health status and in the use of health care services between women and men. Associated factors with a worse self-rated health in both, women and men, were lowest educational level, having three or more chronic diseases, suffering a mental illness, and not performing leisure time physical activity. In relation to educational level, previous studies have showed associations between health status and quality of life and the factors of social support and socio-demographic variables in subjects with self-reported COPD [16], in line with data reported from general population surveys [17]. Also, associations between COPD and health status may be influenced by comorbidities. In this regard, Fan et al. found that comorbidity, in association with other factors such as health care utilization and medication use, contributed to explaining variability in health status [11]. On the other hand, the association between health status and presence of mental illness detected in this study raises an interesting question about whether COPD imposes a greater burden in terms of affective disorders than do other chronic diseases. Indeed, diagnosis of COPD has been associated with a higher probability of unfavorable mental health [18]. Another factor that can influence self-reported health status is age. In our study, older age was associated with a worse self-rated health in women, but not in men. We think this is possibly a consequence of the higher number of comorbid conditions among women than among men. This affects not only physical but also mental conditions. Besides COPD, these conditions independently affect the self-rated health and can justify this association only among women. Finally, it has previously shown that subjects with COPD spend less time walking and standing compared with ageand sex-matched healthy subjects and activity is on a lower intensity level that is not sufficient to promote and maintain health [19]. By contrast, the higher the physical activity levels the better their health and quality of life [15]. Consequently, physical activity should be widely recommended for patients with COPD in COPD guidelines [20]. In relation to the health resources use, having three or more chronic diseases was associated with a higher probability of general practitioner visits, emergency department visits, and hospitalizations in women and men. Our findings are consistent with previous studies demonstrating that COPD has a huge impact, both directly and indirectly through its comorbidity, on various health services [8]. Other authors have also demonstrated that the presence of comorbidities is a major determinant for COPD-related health care use, which should be considered in health plans
123
Lung (2015) 193:53–62
and in disease management programs for COPD [10]. Additionally, in our study, the presence of mental disorders was associated with a higher probability of emergency department visits and hospitalization, respectively, in both gender. These results confirm the impact that mental disorders have on COPD patients. This comorbidity is associated with greater health care utilization and great deterioration of the quality of life [21]. The relationship between the absence of leisure time physical activity and health care resources utilization has also been found in our population, in both women and men. A similar relationship has been described previously [22]. Reduced physical activity is associated with a poorer health-related quality of life [23, 24], a greater risk of hospital admissions [25], and even higher mortality rates [25, 26]. The results of the current study have some potential health policy implications. Firstly, longitudinal cohort studies are needed to reveal the causes of impairment health status and health resources utilization in individuals of COPD in our environment. Secondly, National health policies should focus to improve the COPD management, develop studies assessing the impact of comorbidity and disability in patients and family, and coordinate health interventions among primary care and specialized care to reduce the use of health services, including emergency department visits and hospitalizations. The strengths of our study include large sample sizes, a randomly selected population, the employment of standardized surveys, and training of the data collectors. However, there are also a number of possible limitations. First, our definition of COPD was based on self-reported physician-diagnoses of the disease, and did not rely on lung function test. As such, there might be an issue of recall bias. However, this definition has been widely used in large international surveys [27, 28] and has proved to be reasonably reliable [29]. More recently, it has been shown that the question ‘‘Have you been diagnoses by a physician as having COPD or emphysema’’ is more likely to identify those who do not have the disease due to its high specificity, whereas its low sensitivity could underestimate the real burden of COPD in the general population [30]. However, in analytical epidemiological studies, it is preferable to have a test/question with very high specificity and lower sensitivity, to avoid false positive findings and, consequently, bias in risk estimates [31]. Second, we have not considered institutionalized populations and other forms of health care services such as home and community-based services and emergency assistance, which can influence the outcome of health care service utilization. Third, we have used a self-reported measure of the study variables. Another possible limitation is that person interviewed can possible provide socially conditioned responses. Nevertheless, health surveys are considerable valuable
Lung (2015) 193:53–62
as they collect information related to health problems, which is not available from most other sources of information. In fact, the use of national population-based survey supports the validity of our results because it permits the inclusion of representative population-based sample sizes. On the other hand, the authors believe that longitudinal cohort designs are needed to make a specific temporal relationship. However, the use of cross-sectional National Health Survey has been used previously in Spain and elsewhere to assess the selfrated health status and the use of health care services in different populations and assessing temporal relationships [17, 32–34]. So, for example, Palacios-Cen˜a et al. [32], have recently revealed an increase in health care services utilization from 2001 to 2009 in the older Spanish population. Finally, according to the National Statistics Institute (INE) the initial response rate for the two surveys used in this investigation ranged from 65 % (2006) to 61 % (2012) and it was slightly higher among males and non-Spanish subjects, therefore the existence of possible non-response bias must be considered [13, 14]. This study highlighted that there has been a decrease in the medical practitioner visits, but there has been not changes in the use of other health care services or in the self-rated health status in patients with COPD in Spain in the last years. Therefore, it is necessary to further study the health needs and determinants of health care services use among the COPD population. Our results have clear implications for health and social services in Spain. Health and social services should develop joint programs focused on health promotion (e.g., physical activity), improvement of COPD management and prevention of its progression. These strategies could help to reduce COPD-related health services in an already burdened health system, especially if they can be shown to be cost-effective.
Conflict of interest
The authors report no conflicts of interest.
References 1. Global initiative for chronic obstructive lung disease: global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease (updated 2014). http://www. goldcopd.org/uploads/users/files/GOLD_Report_2014_Jun11.pdf. Accessed 5 Dec 2014 2. Miravitlles M, Soriano JB, Garcı´a-Rı´o F et al (2009) Prevalence of COPD in Spain: impact of undiagnosed COPD on quality of life and daily life activities. Thorax 64(10):863–868 3. Mathers CD, Loncar D (2006) Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med 3(11):e442 4. Blasi F, Cesana G, Conti S et al (2014) The clinical and economic impact of exacerbations of chronic obstructive pulmonary disease: a cohort of hospitalized patients. PLoS ONE 9(6):e101228
61 5. Janson C, Marks G, Buist S et al (2013) The impact of COPD on health status: findings from the BOLD study. Eur Respir J 42(6):1472–1483 6. Carrasco Garrido P, de Miguel Dı´ez J, Gutie´rrez JR et al (2006) Negative impact of chronic obstructive pulmonary disease on the health-related quality of life of patients Results of the EPIDEPOC study. Health Qual Life Outcomes 4:31 7. Gudmundsson G, Gislason T, Janson C et al (2006) Depression, anxiety and health status after hospitalisation for COPD: a multicentre study in the Nordic countries. Respir Med 100(1):87–93 8. Gershon AS, Guan J, Victor JC et al (2013) Quantifying health services use for chronic obstructive pulmonary disease. Am J Respir Crit Care Med 187(6):596–601 9. Sinha SK (2011) Why the elderly could bankrupt Canada and how demographic imperatives will force the redesign of acute care service delivery. Healthc Pap 11(1):46–51 10. Chung K, Kim K, Jung J et al (2014) Patterns and determinants of COPD-related healthcare utilization by severity of airway obstruction in Korea. BMC Pulm Med 14:27 11. Fan VS, Bridevaux PO, McDonell MB et al (2011) Regional variation in health status among chronic obstructive pulmonary disease patients. Respiration 81(1):9–17 12. Gershon AS, Khan S, Klein-Geltink J et al (2014) Asthma and chronic obstructive pulmonary disease (COPD) prevalence and health services use in Ontario Me´tis: a population-based cohort study. PLoS ONE 9(4):e95899 13. Ferna´ndez-Mayoralas G, Rodrı´guez V, Rojo F (2000) Health services accessibility among Spanish elderly. Soc Sci Med 50(1):17–26 14. National Institute of Statistics. Spanish National Health Survey 2006. http://www.msps.es/estadEstudios/estadisticas/encuestaNa cional/encuesta2006.html. Accessed 20 July 2014 15. National Institute of Statistics. Spanish National Health Survey 2011–2012. http://www.ine.es/jaxi/menu.do?type=pcax is&path=%2Ft15/p419&file=inebase&L=1. Accessed 20 July 2014 16. Arne M, Lundin F, Boman G et al (2011) Factors associated with good self-rated health and quality of life in subjects with selfreported COPD. Int J Chron Obstr Pulmon Dis 6:511–519 17. Molarius A, Berglund K, Eriksson C et al (2007) Socioeconomic conditions, lifestyle factors, and self-rated health among men and women in Sweden. Eur J Public Health 17(2):125–133 18. Antwi S, Steck SE, Heidari K (2013) Association between prevalence of chronic obstructive pulmonary disease and healthrelated quality of life, South Carolina, 2011. Prev Chronic Dis 26(10):E215 19. Nelson ME, Rejeski WJ, Blair SN et al (2007) Physical activity and public health in older adults: recommendation from the American College of Sports Medicine and the American Heart Association. Med Sci Sports Exerc 39(8):1435–1445 20. Garcia-Aymerich J, Serra I, Go´mez FP et al (2009) Physical activity and clinical and functional status in COPD. Chest 136(1):62–70 21. Ohayon MM (2014) Chronic obstructive pulmonary disease and its association with sleep and mental disorders in the general population. J Psychiatr Res 54:79–84 22. Garcı´a-Polo C, Alca´zar-Navarrete B, Ruiz-Iturriaga LA et al (2012) Factors associated with high healthcare resource utilisation among COPD patients. Respir Med 106(12):1734–1742 23. Esteban C, Quintana JM, Aburto M et al (2010) Impact of changes in physical activity on health-related quality of life among patients with COPD. Eur Respir J 36(2):292–300 24. Marı´n Royo M, Pellicer Cı´scar C, Gonza´lez Villaescusa C et al (2011) Physical activity and its relationship with the state of health of stable COPD patients. Arch Bronconeumol 47(7):335–342
123
62 25. Garcia-Aymerich J, Lange P, Benet M et al (2006) Regular physical activity reduces hospital admission and mortality in chronic obstructive pulmonary disease: a population based cohort study. Thorax 61(9):772–778 26. Waschki B, Kirsten A, Holz O et al (2011) Physical activity is the strongest predictor of all-cause mortality in patients with COPD: a prospective cohort study. Chest 140(2):331–342 27. de Marco R, Pesce G, Marcon A et al (2013) The coexistence of asthma and chronic obstructive pulmonary disease (COPD): prevalence and risk factors in young, middle-aged and elderly people from the general population. PLoS ONE 8(5):e62985 28. Schnell K, Weiss CO, Lee T et al (2012) The prevalence of clinically-relevant comorbid conditions in patients with physician-diagnosed COPD: a cross-sectional study using data from NHANES 1999–2008. BMC Pulm Med 12:26 29. Buist AS, McBurnie MA, Vollmer WM et al (2007) International variation in the prevalence of COPD (the BOLD Study): a population-based prevalence study. Lancet 370(9589):741–750
123
Lung (2015) 193:53–62 30. Murgia N, Brisman J, Claesson A et al (2014) Validity of a questionnaire-based diagnosis of chronic obstructive pulmonary disease in a general population-based study. BMC Pulm Med 14:49 31. Copeland KT, Checkoway H, McMichael AJ et al (1977) Bias due to misclassification in the estimation of relative risk. Am J Epidemiol 105(5):488–495 32. Palacios-Cen˜a D, Herna´ndez-Barrera V, Jime´nez-Garcı´a R et al (2013) Has the prevalence of health care services use increased over the last decade (2001–2009) in elderly people? A Spanish population-based survey. Maturitas 76(4):326–333 33. Breen N, Gentleman JF, Schiller JS (2011) Update on mammography trends: comparisons of rates in 2000, 2005, and 2008. Cancer 117(10):2209–2218 34. Darnell K, Dwivedi AK, Weng Z et al (2013) Disproportionate utilization of healthcare resources among veterans with COPD: a retrospective analysis of factors associated with COPD healthcare cost. Cost Eff Resour Alloc 11:13
COPD
Trends in Self-Rated Health Status and Health Services Use in COPD Patients (2006–2012). A Spanish Population-Based Survey Javier de Miguel Dı´ez • Rodrigo Jime´nez Garcı´a • Valentı´n Herna´ndez Barrera • Luis Puente Maestu • Maria Isabel del Cura Gonza´lez • Manuel Me´ndez Bailo´n • Pilar Carrasco Garrido • Ana Lo´pez de Andre´s
Received: 15 November 2014 / Accepted: 21 December 2014 / Published online: 31 December 2014 Ó Springer Science+Business Media New York 2014
Abstract Background Chronic obstructive pulmonary disease (COPD) patients often have a significant impairment in their health status, which is an independent predictor of health services use. Objectives To describe the self-rated health status and the prevalence of health services use among COPD Spanish patients; to identify which factors are independently associated with a worse health status and a higher use of health services; and to study the time trends in the health status and prevalence of use of health services (2006–2012). Methods Observational study: We analyzed data from the Spanish National Health Surveys conducted in 2006 and 2012. We included responses from adults aged 40 years or over. Subjects described their health status as very good, good, fair, poor, or very poor, which was dichotomized into
J. de Miguel Dı´ez (&) L. Puente Maestu Department of Respiratory Medicine, Hospital General Universitario Gregorio Maran˜o´n, Instituto de Investigacio´n Sanitaria Gregorio Maran˜o´n (IiSGM), Universidad Complutense de Madrid, C/Doctor Esquerdo 46, 28007 Madrid, Spain e-mail: [email protected] R. Jime´nez Garcı´a V. Herna´ndez Barrera P. Carrasco Garrido A. Lo´pez de Andre´s Preventive Medicine and Public Health Teaching and Research Unit, Department of Health Sciences, Universidad Rey Juan Carlos, Madrid, Spain M. I. del Cura Gonza´lez Unit of Research Support, Technical Direction for Teaching and Research, Attached Management of Planning and Quality, Madrid, Spain M. Me´ndez Bailo´n Department of Internal Medicine, Hospital Clı´nico San Carlos, Madrid, Spain
very good/good or fair/poor/very poor self-perceived health status. Results We identified 2,321 COPD patients. The percentage of patients with health status fair, poor, or very poor was 76.8 % in 2006 and 74.8 % in 2012 (p [ 0.05). Regarding the health resources use, we observed a significant decrease in the number of visits to primary care over time in women (67.8 vs. 57.2 %, p \ 0.05) and men (62.2 vs. 54.0 %, p \ 0.05). However, we did not find improvement in the prevalence of emergency department visits or hospitalizations. Associated factors with a worse self-rated health status and a higher use of health services in women and men included: having three or more chronic diseases, presence of mental disorders, and absence of leisure time physical activity. Conclusions The current study revealed a decrease in the general practitioner visits, without changes in use of other health care services in the COPD Spanish population from 2006 to 2012. The self-rated health status did not changed significantly during this period. Keywords COPD Health status Health services Population-based
Introduction Chronic obstructive pulmonary disease (COPD), including emphysema and chronic bronchitis, is a common disorder characterized by persistent airflow limitation that is usually progressive [1]. Latest estimations in Spain, using the GOLD criteria, set COPD prevalence in 10.2 % in individuals between 40 and 80 years of age [2]. It is an important cause of morbidity and mortality worldwide and, by 2030, is expected to be the third leading cause of death
123
54
and rank seventh as burden of disease [3, 4]. Individuals with COPD may experience disabling respiratory symptoms and they often suffer comorbid conditions [5]. Consequently, these patients often have a significant impairment in their health status [6], which is an independent predictor of health services use and place significant burden on health care systems and society [7, 8]. Current governments are confronted with managing resources in the face of an economic recession [9]. Since patients with COPD are frequent users of health resources, one better understanding of the patterns of use of these services is fundamental for the establishment of health plans geared toward the proper management of COPD and the reduction of overall costs of this disease. However, data about COPD-related health care are lacking [10]. Health status assessment has also been suggested a possible performance measure in evaluation system of care [11]. Administrative data provide a practical way of capturing health services use. It is particularly helpful when it comes from universal, single-payer health care insurance that captures all encounters from a complete real-world population with minimal bias due to financial barriers to care. Following this methodology, Gershan et al. have recently found that individuals with COPD use large and disproportionate amounts of health services, being responsible for up to one-third of all hospitalizations, emergency department visits, ambulatory care visits, long-term care resident places, and home care use in the province of Ontario, Canada [8]. However, it has been demonstrated the existence of geographical variations in medical care so the results cannot be extrapolated to other countries [11, 12]. The Spanish system provides universal health care coverage, with limitations regarding mental, pharmacological, and dental services. In fact, access from primary to specialized (higher) health care levels is determined by first level physician diagnosis [13]. No previous study has determined time trends of use of health care services in people with COPD the last years in Spain. Therefore, this study sought to estimate the self-reported health status and the prevalence of the use of health care services among Spanish COPD patients, associated factors and time trends, using two Spanish National Health Surveys conducted from 2006 to 2012 with particular attention to gender differences. The main objectives of this study were (1) to describe the self-rated health status and the prevalence of general medical practitioner visits within the last 4 weeks and emergency department visits and hospitalizations in the last year according to sex and age groups; (2) to identify which factors, including socio-demographic characteristics, health-related and lifestyle variables, were independently associated to a worse self-rated health status and the higher use of health care services among COPD Spanish patients,
123
Lung (2015) 193:53–62
women and men; and (3) to study the time trends in the self-rated health status and in the prevalence of the use of health care services over the period 2006–2012.
Methods Study Design and Population A repeated cross-sectional study was conducted using individualized data drawn from two National Health Surveys conducted in Spain in the years 2006 (n = 29,478) and 2012 (n = 21,007). These surveys were performed by the Ministry of Health and Consumer Affairs and the National Statistics Institute (Instituto Nacional de Estadı´stica—INE). The national survey is an ongoing, home-based personal interview examining a national representative sample of non-institutionalized population residing in main family dwellings (households) of Spain. It uses a multistage cluster sampling with proportional random selection of primary and secondary sampling units (towns and sections, respectively), with the final units (individuals) being selected by means of random routes and sex- and age-based quotas. All the surveys included provide a representative sample for the Spanish non-institutionalized population residing in main family dwellings (households). Surveyors were previously trained about basic communication skills, procedure, and the questionnaire. More details of the survey methodologies are described elsewhere [14, 15]. For study purposes of the current study, subjects aged 40 years or over were selected from the NHS 2006 (n = 20,060) and NHS 2012 (n = 14,584). We identified individuals suffering COPD as those that answered ‘‘yes’’ to the question ‘‘has your doctor told you that you are currently suffering from chronic bronchitis, emphysema, or COPD?’’ The variables included in the current study were created on the basis of a series of questions identically worded in the questionnaires and identical in the two surveys. The questions used to assess the use of health care services were (1) have you been admitted to a hospital for at least one night in the preceding year?; (2) have you visited an emergency department for any medical situation in the last year?; (3) have you visited a general physician for any medical situation in the last 4 weeks? Independent variables included socio-demographic characteristics such as age (40–54, 55–69 and 70 years or older), gender, nationality (immigrant or Spanish), size of town (\50,000 or C50,000 inhabitants), educational level (no studies, primary or secondary education completed), social class (it was defined using information from monthly income: low \850 €, medium 850–1,400 €, or high [1,400 €), living with a partner (yes/no), occupancy
Lung (2015) 193:53–62
55
(working or non-working), smoking habit (current smokers, ex-smokers or non-smokers), and body mass index (BMI, calculated from self-reported body weight and height). Individuals with a BMI C30 were classified as obese. Further, physical exercise habits applied to cases where subjects acknowledged doing no physical activity in their leisure time. Self-rated health status was assessed with the following question: ‘‘How do you self-rate your health status over the previous 12 months?’’ Subjects described their health status as very good, good, fair, poor, very poor. The answer was dichotomized into very good/good or fair/poor/very poor perceived health status. We also collected the number of medical diagnoses of comorbid chronic conditions including diabetes, high blood pressure, asthma, heart disease, myocardial infarction, cancer, arthritis, and stroke. To identify individuals with associated chronic conditions, we used self-reported affirmative answer to the presence of any physician diagnosed concomitant diseases. The number of medical diagnoses was categorized as none, one or two, and three or more. Finally, information regarding mental disorders (depression and/or anxiety) was obtained from the questionnaires. The presence of mental disease was assessed using the following questions: (1) ‘‘has your doctor told you that you are currently suffering from depression?’’, and (2) has your doctor told you that you are currently suffering from anxiety?’’. Those who answered yes to questions 1 and/or 2 were classified as mental disease sufferers.
variables for the multivariate analysis. We included all the variables whose bivariate tests were significant and those we considered scientifically relevant according to the references reviewed; (3) in order to fit the multivariate model the importance of each variable included in the model was verified. This included the examination of the Wald statistic for each variable and comparison of each estimated coefficient with the coefficient from the bivariate model containing only that variable; and (4) once the model was obtained, we looked more closely at the variables included (linearity) and checked for interactions in the model. The results of the logistic regression models are reported as adjusted odds ratios (ORs) with their 95 % confidence intervals. The estimates were made using the ‘‘svy’’ (survey command) functions of the STATA program (StataCorp LP, Lakeway Drive, College Station, TX, USA), which allowed us to incorporate the study design and weights in all our statistical calculations. Statistical significance was established at p \ 0.05 (two-tailed p values).
Statistical Analysis
Results
All data analyses were performed separately for women and men. First, we estimated the distribution of the sample according to the study variables for each National Health Survey. Second, we calculated and compared the prevalence self-rated health and use of health care service variables according to age groups in each of the two surveys. To perform bivariate comparisons, we used the Chisquare test for trend statistics for categorical variables and two-sided independent t tests for continuous variables. Third, for each dependent variable (self-rated health, general practitioner visit, utilization of the emergency department, and hospitalizations), we then fitted multivariate logistic regression models. With these models, we identified those study variables independently associated with the perception and the use of health care services and assessed the time trend from 2006 to 2012. The logistic regression multivariate model was conducted joining the databases for the two health surveys, NHS 2006 and NHS 2012. It was created using the ‘‘enter modeling’’ method. The process included four steps: (1) bivariate analysis of each variable; (2) selection of the
The total number of subjects with COPD included in the study was 2,321 (2006: n = 1,320; 2012: n = 1,001). The prevalence of COPD in NHS 2006 and NHS 2012 was 6.58 % (95 % CI 6.24–6.92), and 6.86 % (95 % CI 6.45–7.27), respectively. Table 1 shows the distribution, according to age and sex, of the variables included in the study. Overall, we did not find differences in self-rated health of patients with COPD between 2006 and 2012. Thus, the percentage of patients with fair, poor, or very poor perceived health status was 76.8 % in 2006 and 74.8 % in 2012 (p [ 0.05). Furthermore, after adjusting for possible confounders the time trend remained not significant (adjusted OR 1.13, 95 % CI 0.73–1.75). Regarding the health resources use, we observed a significant decrease in the number of visits to primary care over time (64.7 vs. 55.5 %), in both women (67.8 vs. 57.2 %) and men (62.2 vs. 54.0 %). In contrast, we did not find improvement in the percentage of emergency department visits (45.5 vs. 46.6 %) or hospitalizations (22.6 vs. 20.4 %). Tables 2 and 3 show the distribution of the self-rated health and the health resources use according the study
Ethical Aspects As this analysis was conducted on de-identified, public-use datasets, it was not necessary to have the approval of an ethics committee according to Spanish legislation. The participants gave their written informed consent to participate in the surveys and also that the results were published.
123
56
Lung (2015) 193:53–62
Table 1 Distribution, according to age and sex, of the variables included in the Spanish National Health Surveys (NHS) conducted in 2006 and 2012 Variables
Women
Men
Total
Categories
Self-rated health fair/poor/ very poor n (%)
General practitioner visit last 4 weeks n (%)
Hospitalizationlast 12 months n (%)
Emergengy department visit last 12 months n (%)
NHS 2006
NHS 2006
NHS 2012
NHS 2006
NHS 2012
NHS 2006
NHS 2012
99 (57.9)
19 (11.9)
18 (10.4)
74 (45.7)
89 (52.3)
33 (15.4)
32 (13.6)
90 (42.5)
90 (38.7)
NHS 2012
Age (years) 40–54
100 (61.3)
97 (57.2)
98 (60.5)
55–69
176 (82.9)*
163 (70.2)
154 (72.3)*
125 (54)
70 or more
242 (90.9)
274 (87.5)
183 (68.7)
185 (59.2)
64 (20.5)
133 (50.1)
175 (55.8)
Total
518 (80.8)
534 (74.7)
435 (67.8)*
409 (57.2)
134 (20.9)
114 (15.9)
298 (46.5)
353 (49.4)
82 (30.9)*
Age (years) 40–54
76 (62.4)
58 (47.6)
57 (41)
21 (17.4)
21 (15.3)
50 (41)
55–69
205 (70.6)
209 (72)
91 (65.5)
172 (59.3)*
140 (48.2)
56 (19.2)
57 (19.6)
131 (45.3)
69 (49.8)
70 or more
278 (79.7)
316 (80.3)
243 (69.7)
247 (62.8)
105 (30.1)
122 (30.9)
158 (45.3)
184 (46.6)
Total
558 (73.5)
616 (74.8)
472 (62.2)*
444 (54)
182 (23.9)
200 (24.3)
339 (44.6)
363 (44.1)
175 (61.8)
188 (60.9)
156 (55)
155 (50.3)
40 (14.2)
39 (12.6)
124 (43.7)
158 (51.2)
381 (75.8)
371 (71.2)
325 (64.8)*
265 (50.8)
88 (17.6)
88 (17)
221 (44.1)
200 (38.3)
520 (84.6) 1,076 (76.8)
590 (83.5) 1,149 (74.8)
426 (69.2)* 907 (64.7)*
433 (61.2) 853 (55.5)
187 (30.5) 316 (22.6)
186 (26.3) 313 (20.4)
291 (47.4) 637 (45.5)
358 (50.7) 716 (46.6)
110 (38)
Age (years) 40–54 55–69 70 or more Total
* Significant association between study variables and Spanish National Health Survey
variables, in the two national surveys conducted in Spain between 2006 and 2012, in men and women, respectively. When comparing the results of the two surveys, we found a worsening of self-rated health status in patients with three or more chronic diseases in men and in patients with three or more chronic diseases in women. Additionally, in women, we observed a decrease in this variable over time, in those with active work, in those who consumed alcohol and those who did not practice physical activity in their free time. Regarding the health resources use, the most consistent improvements occurred in relation to visits to primary care, especially among women. Table 4 shows the variables that were significantly associated with a worse self- rated health status, and with a higher use of health care services among Spanish women and men, with the adjusted OR and their corresponding 95 % confidence intervals. Associated factors with a worse self-rated health in both, women and men, were lowest educational level, having three or more chronic diseases, suffering mental disorders, and not practice of leisure time physical activity. In addition, older age was also associated with a worse self-rated health in women, but not in men. In relation to the health resources use, having three or more chronic diseases was associated with a higher probability of general practitioner visits (OR 2.02, 95 % CI 1.14–3.57 in women; OR 1.75, 95 % CI 1.03–2.95 in men), emergency department visits (OR 1.87, 95 % CI 1.14–3.09 in women; OR 2.45, 95 % CI 1.43–4.19 in men), and hospitalizations (OR 5.04, 95 % CI 2.21–11.48 in women;
123
OR 3.06, 95 % CI 1.70–5.50 in men) in women and men. Additionally, the presence of mental disorders and the absence of practice of leisure time physical activity were variables associated with a lower probability of emergency department visits and hospitalization, respectively, in both gender. Other factors related to health resources utilization in women were being married and having a lower social class, which were associated with a higher probability of visits to the general practitioner (Table 4). For men, a higher age was associated with a higher probability of general practitioner visits, but neither to emergency room visits nor hospitalizations. Moreover, women and men that were not drinkers had a higher probability of general practitioner visits (Table 4). Finally, the multivariate analysis, showed that the time trend of the number of visits to the general practitioner significantly decreased in women and men from 2006 to 2012. However, no significant variations for emergency department visits or hospitalizations were observed in either women or men. Furthermore, we did not find significant changes in the state of self-rated health during that period, neither in women or men (Table 4).
Discussion The nationally representative data of the current study reveals a high use of health care services in the Spanish COPD population, although we have observed a decrease
Lung (2015) 193:53–62
57
Table 2 Distribution of the self-rated health ‘‘fair/poor/very poor’’ and the health resources use according the study variables, in the two National Health Surveys (NHS) conducted in Spain between 2006 and 2012, in women Women
Self-rated health ‘‘fair/ poor/very poor’’ n (%)
General practitioner visit last 4 weeks n (%)
Hospitalization last 12 months n (%)
Emergency department visit last 12 months n (%)
NHS 2006
NHS 2006
NHS 2006
NHS 2006
NHS 2012
NFS 2012
NHS 2012
NHS 2012
Living with a partner No
238 (87.1)
269 (81.9)
171 (62.8)
184 (56)
66 (24.1)
52 (16.0)
140 (51.3)
178 (54.2)
Yes
278 (76)
264 (68.5)
262 (71.3)*
225 (58.3)
68 (18.6)
61 (15.8)
158 (43.1)
175 (45.4)
Nationality Immigrant
5 (25.7)
16 (46.8)
0 (0)
3 (9.2)
8 (37.1)
11 (31.1)
504 (81.5)*
511 (75)
427 (69.1)*
393 (57.7)
134 (21.7)
110 (16.2)
290 (46.9)
343 (50.4)
\50,000
274 (84)
268 (77.9)
231 (70.8)*
203 (59)
74 (22.8)
68 (19.8)
155 (47.4)
160 (46.6)
C50,000
207 (78.1)
265 (71.7)
176 (66.6)*
206 (55.6)
49 (18.6)
45 (12.3)
118 (44.5)
193 (52.1)
Spanish
12 (58.3)
23 (67.5)
Town size (inhabitants)
Educational level Secundary or more Primary
68 (63)
61 (47.8)
61 (56.2)
66 (51.9)
14 (13)
10 (8.2)
43 (39.8)
50 (38.8)
444 (84.2)
473 (80.6)
368 (69.8)*
343 (58.4)
116 (21.9)
103 (17.6)
250 (47.5)
304 (51.8)
130 (77.7) 294 (81.5)
201 (74.4) 325 (75.4)
100 (59.8) 257 (71.5)*
144 (53.2) 258 (59.8)
36 (21.2) 66 (18.4)
43 (16) 70 (16.3)
71 (42.5) 169 (47)
138 (50.9) 211 (48.9)
Social class High–medium Low Occupation Working Not working
65 (52.1)
75 (64.8)*
53 (43)
12 (10.4)
450 (85.5)*
68 (59)
469 (79.4)
360 (68.5)*
356 (60.2)
122 (23.2)
11 (9)
31 (44.6)
151 (54.1)
37 (53.3)
135 (48.4)
7 (10.6)
14 (5.1)
25 (36.6)
111 (39.8)
286 (84.5)
257 (66.9)
211 (62.4)
66 (17.1)
69 (20.3)
167 (43.5)*
187 (55.4)
63 (64.7)
61 (32.6)
31 (31.5)
105 (56.2)
55 (56.2)
102 (17.3)
47 (41.2)
43 (34.8)
251 (47.6)
310 (52.5)
Number of chronic condition None 1–2
311 (81)
3 or more
176 (93.7)*
97 (99.5)
No
242 (71.5)
262 (65.1)
214 (63.3)*
215 (53.5)
72 (21.4)
59 (14.6)
132 (39.2)
172 (42.6)
Yes
276 (91)
271 (87)
221 (72.8)*
193 (62.1)
62 (20.4)
55 (17.6)
166 (54.5)
182 (58.2) 68 (45.1)
141 (75)
Mental disorders
Smoker Smoker
72 (62.1)
87 (57.4)
68 (58.1)
76 (50.3)
15 (13.3)*
7 (4.3)
54 (46.6)
Ex-smoker
46 (70.3)
45 (54.4)
40 (62)
40 (48.8)
15 (22.4)
13 (15.9)
17 (25.7)
32 (39.2)
Non-smoker Drinker
400 (86.9)
402 (83.6)
327 (71.1)*
292 (60.8)
104 (22.6)
94 (19.5)
227 (49.3)
253 (52.6)
No
386 (84.7)
413 (81.8)
318 (69.9)
311 (61.6)
105 (23)
94 (18.6)
218 (47.9)
245 (48.6)
Yes
132 (71)*
121 (57.6)
116 (62.7)*
98 (46.6)
29 (15.7)
20 (9.4)
80 (43)
108 (51.5)
No
278 (84.4)
345 (84.8)
218 (66.3)
245 (60.2)
86 (26.1)
82 (20.3)
174 (53)
209 (51.4)
Yes
240 (76.9)*
189 (61.3)
217 (69.4)*
164 (53.2)
48 (15.5)
31 (10.1)
124 (39.6)
144 (46.8)
Physical exercise
BMI \30
268 (75.6)
250 (67.0)
224 (63.2)
199 (53.2)
66 (18.6)*
43 (11.5)
157 (44.3)
170 (45.5)
C30
142 (89.6)
207 (83.8)
115 (72.5)
150 (60.5)
32 (20.5)
50 (20.2)
79 (50.2)
131 (52.8)
* Significant association between study variables and Spanish National Health Survey
in the general practitioner visits in the last month. However, there have been not variations in the use of other health care services, such as emergency department visits or hospitalizations. The reduction in the number of visits to primary care is relevant since in the Spanish National
Health Service the primary care is the first step in the health assistance. We believe that a better management of the COPD patients at this level, including an earlier diagnosis and improved therapies, are the reasons for the lower number of visits. We also think that possibly in the next
123
58
Lung (2015) 193:53–62
Table 3 Distribution of the self-rated health and the health resources use according the study variables, in the two National Health Surveys (NHS) conducted in Spain between 2006 and 2012, in men Men
Self-rated health ‘‘fair/ poor/very poor’’ n (%)
General practitioner visits last 4 weeks n (%)
Hospitalization last 12 months n (%)
Emergency department visit last 12 months n (%)
NHS 2006
NHS 2006
NHS 2006
NHS 2006
NHS 2012
NFS 2012
NHS 2012
NHS 2012
Living with a partner No
140 (69.8)
152 (69.6)
122 (60.8)
106 (48.6)
Yes
414 (75)
464 (76.8)
347 (62.7)
338 (55.9)
49 (24.5) 133 (24)
46 (21.1)
79 (39.5)
98 (44.8)
154 (25.4)
253 (45.8)
265 (43.9)
Nationality Immigrant
7 (100)
22 (56.3)
3 (39.8)
24 (59.2)
1 (12.8)
7 (18.4)
6 (82.8)
12 (30.5)
551 (74.1)
593 (75.8)
463 (62.3)*
420 (53.7)
181 (24.3)
192 (24.6)
330 (44.4)
351 (44.8)
\50,000
303 (73.6)
281 (76.7)
260 (63.1)
206 (56.1)
81 (19.6)
98 (26.8)
169 (41)
173 (47.3)
C50,000
196 (74.5)
335 (73.4)
164 (62.3)
238 (52.3)
66 (25.2)
102 (22.3)
119 (45.3)
190 (41.5)
Spanish Town size (inhabitants)
Educational level Secundary or more Primary
86 (61.5)
101 (57.9)
87 (62.3)
84 (48.3)
33 (23.8)
32 (18.3)
54 (39)
63 (35.9)
470 (76.8)
514 (79.4)
380 (62.1)
359 (55.5)
146 (23.9)
168 (25.9)
282 (46)
300 (46.4)
174 (66.3) 377 (77.4)
219 (73.7) 378 (75.2)
177 (67.5)* 289 (59.4)
152 (51.1) 281 (56)
69 (26.3) 110 (22.7)
74 (24.7) 118 (23.5)
105 (39.8) 228 (46.9)
145 (48.8) 207 (41.2)
Social class High–medium Low Occupation Working
107 (62.8)
78 (59.7)
81 (47.6)
51 (39)
31 (17.9)
Not working
451 (76.6)
538 (77.7)
391 (66.4)*
393 (56.8)
151 (25.7)
20 (15.3) 180 (26)
72 (42.3)
40 (30.4)
267 (45.3)
323 (46.7)
Number of chronic condition None
93 (57.6)
248 (63.7)
77 (47.7)
175 (44.9)
24 (14.7)
54 (13.9)
68 (42.2)
136 (34.8)
1–2
310 (74.7)*
294 (83.3)
263 (63.4)
227 (64.3)
94 (22.6)*
115 (32.6)
160 (38.6)*
179 (50.9)
3 or more
155 (84.8)
74 (91.7)
132 (72.2)*
42 (52.5)
64 (35.2)
31 (38.1)
111 (60.5)
48 (59.7)
150 (24.9)
131 (20.5)
271 (44.8)
246 (38.4)
68 (37.7)
67 (43.9)
117 (64.5)
Mental disorders No
424 (70)
459 (71.6)
372 (61.4)*
336 (52.3)
Yes
134 (87.1)
157 (86.5)
100 (65.1)
108 (59.7)
31 (20.3)*
Smoker Smoker
144 (75.3)
143 (65.7)
94 (49.2)
86 (39.3)
Ex-smoker
324 (73.8)
345 (80.2)
288 (65.6)
262 (60.9)
Non-smoker Alcohol drink
90 (69.7)
90 (69.8)
96 (55.1)
127 (73)
20 (10.5) 132 (30)
23 (10.5)
67 (35.2)*
82 (37.8)
133 (30.8)
218 (49.6)
209 (48.6)
30 (23.3)
44 (25.4)
54 (41.8)
71 (40.9)
No
212 (82)
333 (83.2)
177 (68.4)
253 (63.1)
67 (25.8)
111 (27.9)
123 (47.6)
211 (52.6)
Yes
346 (69.1)
283 (66.9)
295 (59)*
191 (45.3)
115 (22.9)
88 (20.9)
216 (43.1)
152 (36.1)
No
257 (77.8)
375 (79.6)
201 (60.7)
266 (56.5)
90 (27.1)
140 (29.7)
163 (49.4)
226 (48)
Yes
301 (70.1)
241 (68.5)
271 (63.3)*
178 (50.6)
92 (21.5)
60 (17)
175 (41)
137 (38.9)
119 (24.2)
116 (22.1)
218 (44.5)
40 (22.3)
52 (23.2)
76 (42)
Physical exercise
BMI \30
365 (74.4)
368 (69.8)
296 (60.3)
274 (52)
C30
130 (72.1)*
188 (84.6)
119 (66)
123 (55.3)
210 (39.8) 111 (50)
* Significant association between study variables and Spanish National Health Survey
years, the improvement in the primary care will also result in a reduction of the emergency department visits or hospitalizations. This study also shows that a high proportion of patients with COPD in Spain have fair, poor, or very poor self-rated
123
health and it has not changed significantly in the last years (76.8 % in 2006 and 74.8 % in 2012). Furthermore, after adjusting for possible confounders the time trend remained not significant (adjusted OR, 1.13 95 % CI 0.73–1.75). This means that even if the use of primary care services has
1 1.13 (0.73–1.75)
2012
1.81 (1.19–2.76)
No
2006
1
NS
Yes
No
NS
Non-smoker 1
NS
Ex-smoker
Yes
1
2.92 (1.85–4.64)
Smoker
Yes
3 or more 1
2.59 (1.62–4.14) 8.74 (4.07–18.76)
1–2
No
1
NS
Low
None
1
1.89 (1.17–3.05)
Primary
High–medium
1
NS
Yes
Secundary or more
1
No
2.59 (1.50–4.48)
70 or more
1
0.69 (0.44–0.97)
1
NS
1
1.52 (1.05–2.18)
1
NS
NS
1
1.45 (1.02–2.05)
1
2.02 (1.14–3.57)
1.57 (1.03–2.40)
1
1.51 (1.07–2.14)
1
NS
1
1.48 (1.04–2.10)
1
0.93 (0.57–1.52)
0.81 (0.51–1.30)
0.90 (0.58–1.40)
1
1.67 (1.11–2.50)
1
NS
1
NS
NS
1
NS
1
5.04 (2.21–11.48)
2.71 (1.28–5.76)
1
NS
1
NS
1
NS
1
1.60 (0.84–3.05)
1.06 (0.54–2.09)
1
1.34 (0.97–1.84)
1
NS
1
NS
1
NS
NS
1
1.75 (1.29–2.37)
1
1.87 (1.14–3.09)
1.48 (0.99–2.21)
1
NS
1
NS
1
NS
1
0.93 (0.61–1.42)
0.60 (0.40–0.91)
1
1.20 (0.80–1.79)
1
1.45 (1.01–2.15)
1
1.96 (1.29–2.97)
1
NS
NS
1
2.20 (1.31–3.69)
1
3.64 (1.69–7.82)
2.17 (1.41–3.31)
1
NS
1
2.09 (1.34–3.27)
1
NS
1
1.14 (0.65–2.03)
0.83 (0.47–1.45)
1
0.73 (0.47–0.96)
1
NS
1
1.61 (1.15–2.26)
1
NS
NS
S
NS
1
1.75 (1.03–2.95)
1.77 (1.22–2.58)
1
NS
1
NS
1
NS
1
1.92 (1.17–3.14)
1.25 (0.76–2.06)
1
GP OR (CI 95 %)
1.23 (0.84–1.82)
1
1.68 (1.17–2.43)
1
NS
1
2.30 (1.23–4.30)
3.12 (1.80–5.30)
1
NS
1
3.06 (1.70–5.50)
2.13 (1.32–3.43)
1
NS
1
NS
1
NS
1
1.08 (0.54–2.14)
0.80 (0.38–1.65)
1
Hospital OR (CI 95 %)
1.11 (0.79–1.56)
1
1.44 (1.05–1.98)
1
NS
1
1.19 (0.73–1.95)
1.69 (1.10–2.57)
1
1.52 (1.04–2.22)
1
2.45 (1.43–4.19)
1.37 (0.92–2.04)
1
NS
1
NS
1
NS
1
0.68 (0.40–1.12)
0.65 (0.39–1.10)
1
ED OR (CI 95 %)
NS not significant, SRH self-rated health fair/poor/very poor, GP general practitioner visit last 4 weeks, Hospital hospitalization last 12 months, ED emergency department visit last 12 months
ENS
Physical exercise
Alcohol drink
Smoker
Mental disorders
Number of chronic conditions
Social class
Educational level
Living with a partner
1 1.72 (1.04–2.84)
40–54
Age groups (years)
ED OR (CI 95 %)
SRH OR (CI 95 %)
Hospital OR (CI 95 %)
SRH OR (CI 95 %)
GP OR (CI 95 %)
Men
Women
55–69
Categories
Variables
Table 4 Adjusted OR for self- rated health and health care services among Spanish COPD patients, women and men, included in the Spanish National Health Surveys (NHS) conducted in 2006 and 2012 (the multivariate model was conducted joining the databases for the two health surveys, NHS 2006 and NHS 2012)
Lung (2015) 193:53–62 59
123
60
decreased over the study period, the patients suffering COPD have not improved their self-rated health so it is necessary to continue searching for strategies to raise the quality of life for these patients. Our study also demonstrates that there are only few differences in the self-reported health status and in the use of health care services between women and men. Associated factors with a worse self-rated health in both, women and men, were lowest educational level, having three or more chronic diseases, suffering a mental illness, and not performing leisure time physical activity. In relation to educational level, previous studies have showed associations between health status and quality of life and the factors of social support and socio-demographic variables in subjects with self-reported COPD [16], in line with data reported from general population surveys [17]. Also, associations between COPD and health status may be influenced by comorbidities. In this regard, Fan et al. found that comorbidity, in association with other factors such as health care utilization and medication use, contributed to explaining variability in health status [11]. On the other hand, the association between health status and presence of mental illness detected in this study raises an interesting question about whether COPD imposes a greater burden in terms of affective disorders than do other chronic diseases. Indeed, diagnosis of COPD has been associated with a higher probability of unfavorable mental health [18]. Another factor that can influence self-reported health status is age. In our study, older age was associated with a worse self-rated health in women, but not in men. We think this is possibly a consequence of the higher number of comorbid conditions among women than among men. This affects not only physical but also mental conditions. Besides COPD, these conditions independently affect the self-rated health and can justify this association only among women. Finally, it has previously shown that subjects with COPD spend less time walking and standing compared with ageand sex-matched healthy subjects and activity is on a lower intensity level that is not sufficient to promote and maintain health [19]. By contrast, the higher the physical activity levels the better their health and quality of life [15]. Consequently, physical activity should be widely recommended for patients with COPD in COPD guidelines [20]. In relation to the health resources use, having three or more chronic diseases was associated with a higher probability of general practitioner visits, emergency department visits, and hospitalizations in women and men. Our findings are consistent with previous studies demonstrating that COPD has a huge impact, both directly and indirectly through its comorbidity, on various health services [8]. Other authors have also demonstrated that the presence of comorbidities is a major determinant for COPD-related health care use, which should be considered in health plans
123
Lung (2015) 193:53–62
and in disease management programs for COPD [10]. Additionally, in our study, the presence of mental disorders was associated with a higher probability of emergency department visits and hospitalization, respectively, in both gender. These results confirm the impact that mental disorders have on COPD patients. This comorbidity is associated with greater health care utilization and great deterioration of the quality of life [21]. The relationship between the absence of leisure time physical activity and health care resources utilization has also been found in our population, in both women and men. A similar relationship has been described previously [22]. Reduced physical activity is associated with a poorer health-related quality of life [23, 24], a greater risk of hospital admissions [25], and even higher mortality rates [25, 26]. The results of the current study have some potential health policy implications. Firstly, longitudinal cohort studies are needed to reveal the causes of impairment health status and health resources utilization in individuals of COPD in our environment. Secondly, National health policies should focus to improve the COPD management, develop studies assessing the impact of comorbidity and disability in patients and family, and coordinate health interventions among primary care and specialized care to reduce the use of health services, including emergency department visits and hospitalizations. The strengths of our study include large sample sizes, a randomly selected population, the employment of standardized surveys, and training of the data collectors. However, there are also a number of possible limitations. First, our definition of COPD was based on self-reported physician-diagnoses of the disease, and did not rely on lung function test. As such, there might be an issue of recall bias. However, this definition has been widely used in large international surveys [27, 28] and has proved to be reasonably reliable [29]. More recently, it has been shown that the question ‘‘Have you been diagnoses by a physician as having COPD or emphysema’’ is more likely to identify those who do not have the disease due to its high specificity, whereas its low sensitivity could underestimate the real burden of COPD in the general population [30]. However, in analytical epidemiological studies, it is preferable to have a test/question with very high specificity and lower sensitivity, to avoid false positive findings and, consequently, bias in risk estimates [31]. Second, we have not considered institutionalized populations and other forms of health care services such as home and community-based services and emergency assistance, which can influence the outcome of health care service utilization. Third, we have used a self-reported measure of the study variables. Another possible limitation is that person interviewed can possible provide socially conditioned responses. Nevertheless, health surveys are considerable valuable
Lung (2015) 193:53–62
as they collect information related to health problems, which is not available from most other sources of information. In fact, the use of national population-based survey supports the validity of our results because it permits the inclusion of representative population-based sample sizes. On the other hand, the authors believe that longitudinal cohort designs are needed to make a specific temporal relationship. However, the use of cross-sectional National Health Survey has been used previously in Spain and elsewhere to assess the selfrated health status and the use of health care services in different populations and assessing temporal relationships [17, 32–34]. So, for example, Palacios-Cen˜a et al. [32], have recently revealed an increase in health care services utilization from 2001 to 2009 in the older Spanish population. Finally, according to the National Statistics Institute (INE) the initial response rate for the two surveys used in this investigation ranged from 65 % (2006) to 61 % (2012) and it was slightly higher among males and non-Spanish subjects, therefore the existence of possible non-response bias must be considered [13, 14]. This study highlighted that there has been a decrease in the medical practitioner visits, but there has been not changes in the use of other health care services or in the self-rated health status in patients with COPD in Spain in the last years. Therefore, it is necessary to further study the health needs and determinants of health care services use among the COPD population. Our results have clear implications for health and social services in Spain. Health and social services should develop joint programs focused on health promotion (e.g., physical activity), improvement of COPD management and prevention of its progression. These strategies could help to reduce COPD-related health services in an already burdened health system, especially if they can be shown to be cost-effective.
Conflict of interest
The authors report no conflicts of interest.
References 1. Global initiative for chronic obstructive lung disease: global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease (updated 2014). http://www. goldcopd.org/uploads/users/files/GOLD_Report_2014_Jun11.pdf. Accessed 5 Dec 2014 2. Miravitlles M, Soriano JB, Garcı´a-Rı´o F et al (2009) Prevalence of COPD in Spain: impact of undiagnosed COPD on quality of life and daily life activities. Thorax 64(10):863–868 3. Mathers CD, Loncar D (2006) Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med 3(11):e442 4. Blasi F, Cesana G, Conti S et al (2014) The clinical and economic impact of exacerbations of chronic obstructive pulmonary disease: a cohort of hospitalized patients. PLoS ONE 9(6):e101228
61 5. Janson C, Marks G, Buist S et al (2013) The impact of COPD on health status: findings from the BOLD study. Eur Respir J 42(6):1472–1483 6. Carrasco Garrido P, de Miguel Dı´ez J, Gutie´rrez JR et al (2006) Negative impact of chronic obstructive pulmonary disease on the health-related quality of life of patients Results of the EPIDEPOC study. Health Qual Life Outcomes 4:31 7. Gudmundsson G, Gislason T, Janson C et al (2006) Depression, anxiety and health status after hospitalisation for COPD: a multicentre study in the Nordic countries. Respir Med 100(1):87–93 8. Gershon AS, Guan J, Victor JC et al (2013) Quantifying health services use for chronic obstructive pulmonary disease. Am J Respir Crit Care Med 187(6):596–601 9. Sinha SK (2011) Why the elderly could bankrupt Canada and how demographic imperatives will force the redesign of acute care service delivery. Healthc Pap 11(1):46–51 10. Chung K, Kim K, Jung J et al (2014) Patterns and determinants of COPD-related healthcare utilization by severity of airway obstruction in Korea. BMC Pulm Med 14:27 11. Fan VS, Bridevaux PO, McDonell MB et al (2011) Regional variation in health status among chronic obstructive pulmonary disease patients. Respiration 81(1):9–17 12. Gershon AS, Khan S, Klein-Geltink J et al (2014) Asthma and chronic obstructive pulmonary disease (COPD) prevalence and health services use in Ontario Me´tis: a population-based cohort study. PLoS ONE 9(4):e95899 13. Ferna´ndez-Mayoralas G, Rodrı´guez V, Rojo F (2000) Health services accessibility among Spanish elderly. Soc Sci Med 50(1):17–26 14. National Institute of Statistics. Spanish National Health Survey 2006. http://www.msps.es/estadEstudios/estadisticas/encuestaNa cional/encuesta2006.html. Accessed 20 July 2014 15. National Institute of Statistics. Spanish National Health Survey 2011–2012. http://www.ine.es/jaxi/menu.do?type=pcax is&path=%2Ft15/p419&file=inebase&L=1. Accessed 20 July 2014 16. Arne M, Lundin F, Boman G et al (2011) Factors associated with good self-rated health and quality of life in subjects with selfreported COPD. Int J Chron Obstr Pulmon Dis 6:511–519 17. Molarius A, Berglund K, Eriksson C et al (2007) Socioeconomic conditions, lifestyle factors, and self-rated health among men and women in Sweden. Eur J Public Health 17(2):125–133 18. Antwi S, Steck SE, Heidari K (2013) Association between prevalence of chronic obstructive pulmonary disease and healthrelated quality of life, South Carolina, 2011. Prev Chronic Dis 26(10):E215 19. Nelson ME, Rejeski WJ, Blair SN et al (2007) Physical activity and public health in older adults: recommendation from the American College of Sports Medicine and the American Heart Association. Med Sci Sports Exerc 39(8):1435–1445 20. Garcia-Aymerich J, Serra I, Go´mez FP et al (2009) Physical activity and clinical and functional status in COPD. Chest 136(1):62–70 21. Ohayon MM (2014) Chronic obstructive pulmonary disease and its association with sleep and mental disorders in the general population. J Psychiatr Res 54:79–84 22. Garcı´a-Polo C, Alca´zar-Navarrete B, Ruiz-Iturriaga LA et al (2012) Factors associated with high healthcare resource utilisation among COPD patients. Respir Med 106(12):1734–1742 23. Esteban C, Quintana JM, Aburto M et al (2010) Impact of changes in physical activity on health-related quality of life among patients with COPD. Eur Respir J 36(2):292–300 24. Marı´n Royo M, Pellicer Cı´scar C, Gonza´lez Villaescusa C et al (2011) Physical activity and its relationship with the state of health of stable COPD patients. Arch Bronconeumol 47(7):335–342
123
62 25. Garcia-Aymerich J, Lange P, Benet M et al (2006) Regular physical activity reduces hospital admission and mortality in chronic obstructive pulmonary disease: a population based cohort study. Thorax 61(9):772–778 26. Waschki B, Kirsten A, Holz O et al (2011) Physical activity is the strongest predictor of all-cause mortality in patients with COPD: a prospective cohort study. Chest 140(2):331–342 27. de Marco R, Pesce G, Marcon A et al (2013) The coexistence of asthma and chronic obstructive pulmonary disease (COPD): prevalence and risk factors in young, middle-aged and elderly people from the general population. PLoS ONE 8(5):e62985 28. Schnell K, Weiss CO, Lee T et al (2012) The prevalence of clinically-relevant comorbid conditions in patients with physician-diagnosed COPD: a cross-sectional study using data from NHANES 1999–2008. BMC Pulm Med 12:26 29. Buist AS, McBurnie MA, Vollmer WM et al (2007) International variation in the prevalence of COPD (the BOLD Study): a population-based prevalence study. Lancet 370(9589):741–750
123
Lung (2015) 193:53–62 30. Murgia N, Brisman J, Claesson A et al (2014) Validity of a questionnaire-based diagnosis of chronic obstructive pulmonary disease in a general population-based study. BMC Pulm Med 14:49 31. Copeland KT, Checkoway H, McMichael AJ et al (1977) Bias due to misclassification in the estimation of relative risk. Am J Epidemiol 105(5):488–495 32. Palacios-Cen˜a D, Herna´ndez-Barrera V, Jime´nez-Garcı´a R et al (2013) Has the prevalence of health care services use increased over the last decade (2001–2009) in elderly people? A Spanish population-based survey. Maturitas 76(4):326–333 33. Breen N, Gentleman JF, Schiller JS (2011) Update on mammography trends: comparisons of rates in 2000, 2005, and 2008. Cancer 117(10):2209–2218 34. Darnell K, Dwivedi AK, Weng Z et al (2013) Disproportionate utilization of healthcare resources among veterans with COPD: a retrospective analysis of factors associated with COPD healthcare cost. Cost Eff Resour Alloc 11:13
