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IRCCS Policlinico San Matteo

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1 IRCCS Policlinico San Matteo
La Salute del Respiro, epidemiologia, costi sanitari ed implicazioni sociali delle malattie respiratorie croniche ostruttive e delle allergopatie respiratorie Milano, 26 gennaio 2007 La Salute del Respiro: una attualità nazionale Ernesto Pozzi Clinica Malattie Apparato Respiratorio Università di Pavia Fondazione IRCCS Policlinico San Matteo

2 Of the six leading causes of death in the United States, only COPD has been increasing steadily since 1970 Jemal A. et al. JAMA 2005

3 EPIDEMIOLOGICAL PERSPECTIVES
COPD EPIDEMIOLOGICAL PERSPECTIVES “Mortality rates will increase by 50% over the next 15 years” Lopez, ERJ 2006

4 EPIDEMIOLOGICAL PERSPECTIVES
CHANGING GLOBAL DEMOGRAPHICS People > 60yr EPIDEMIOLOGICAL PERSPECTIVES “Mortality rates will increase by 50% over the next 15 years” Lopez, ERJ 2006

5 EPIDEMIOLOGICAL PERSPECTIVES
MORTALITY IN FEMALES EPIDEMIOLOGICAL PERSPECTIVES “Mortality rates will increase by 50% over the next 15 years” Lopez, ERJ 2006

6 COPD Mortality by Gender U.S. 1980-2000
Number Deaths x 1000 Source: US Centers for Disease Control and Prevention, 2002

7 Differences in survival, men vs women,
after initiating long-term oxygen terapy Machado et al AJRCCM 2006

8 CONTINUED USE OF TOBACCO EPIDEMIOLOGICAL PERSPECTIVES
Low rates of smoking cessation (~30%)  Young smokers (particularly females)  Smoking in non-developed countries EPIDEMIOLOGICAL PERSPECTIVES “Mortality rates will increase by 50% over the next 15 years” Lopez, ERJ 2006

9 NET CHANGE IN ACTIVE SMOKING % PER 10 YRS
ECRHS I ; ECRHS II (9053 subjects, age range years at ECRHS I) Janson, Cerveri and ECRHS group ERJ 2006

10 NET CHANGE IN PASSIVE SMOKING % PER 10 YRS
ECRHS I ; ECRHS II (9053 subjects, age range years at ECRHS I) Janson, Cerveri and ECRHS group ERJ 2006

11 Global Epidemiology of Smoking

12 EPIDEMIOLOGICAL PERSPECTIVES
OTHER RISK FACTORS Occupation Pollution Indoor outdoor EPIDEMIOLOGICAL PERSPECTIVES “Mortality rates will increase by 50% over the next 15 years” Lopez, ERJ 2006

13 AIR POLLUTION AND LUNG FUNCTION IN THE ECRHS
Rationale: Long term effects of air pollution on lung function have not been studied across European adult populations before, and in particular evidence for effects on change in lung function among adults is weak. Gotschi, Sunyier and ECRHS group Lancet, submitted

14 Geographical distribution of ECRHS centres

15 PM2.5 levels across ECRHS centres

16 AIR POLLUTION AND LUNG FUNCTION IN THE ECRHS
Measurements and Main Results: No significant associations were found between PM2.5 and any of the lung function measures neither for lung function level nor for change in lung function. Conclusions: The heterogeneity of the studied populations in combination with limitations of the cross-community comparison approach are plausible explanations of the observed null-findings.Future studies on long term effects of air pollution on lung function should be based on within-community comparisons. Gotschi, Sunyier and ECRHS group Lancet, submitted

17 Chapman et al. ERJ 2006 COPD PREVALENCE
Prevalenza di COPD in aumento costante >10% tra la popolazione > 40 anni Chapman et al. ERJ 2006 Prevalenza di COPD 3.6% tra la popolazione di eta’ years de Marco et al. Thorax 2004

18 INCIDENCE OF COPD ACCORDING TO THE HISTORY OF CHRONIC COUGH AND PHLEGM
De Marco, Cerveri et al AJRCCM 2006

19 EPIDEMIOLOGICAL PERSPECTIVES
GLOBAL BURDEN Hospitalizations Number and duration Comorbidity EPIDEMIOLOGICAL PERSPECTIVES “Mortality rates will increase by 50% over the next 15 years” Lopez, ERJ 2006

20 Aumento del numero dei ricoveri per BPCO dal 1999 al 2003 in Italia
N° RICOVERI DRG 88 = malattia polmonare cronica ostruttiva DRG 87 = edema polmonare e insufficienza respiratoria DRG 475 = diagnosi relative all'apparato respiratorio con respirazione assistita

21 EXACERBATIONS AS A STARTING POINT OF PROACTIVE COPD MANAGEMENT
Zoia et al, Resp Med 2005

22 Patients with and without previous diagnosis
EXACERBATIONS AS A STARTING POINT OF PROACTIVE COPD MANAGEMENT Patients with and without previous diagnosis Without diagnosis With diagnosis

23 Percentage of patients with and without spirometry
EXACERBATIONS AS A STARTING POINT OF PROACTIVE COPD MANAGEMENT Percentage of patients with and without spirometry

24 EXACERBATIONS AS A STARTING POINT OF PROACTIVE COPD MANAGEMENT

25

26 Epidemiologia della BPCO
Ricoveri in regime ordinario Diagnosi principale n. dimissioni degenza media Malattia polmonare cronica ostruttiva 120188 10.01 Bronchite cronica ostruttiva, riacutizzata 88083 9.77 Insufficienza respiratoria 70054 13.15 Bronchite cronica ostruttiva, non riacutizzata 22978 12.00 Bronchite, non specificata se acuta o cronica 4216 4.69 Bronchite cronica semplice 2328 10.04 Bronchite cronica non specificata 2039 9.36 Bronchite cronica mucopurulenta 1256 10.33 SDO - Ministero della Salute, 2005

27 COPD Exacerbations : Mortality
1016 pts with severe COPD exacerbation (PaCO2 > 50 mm Hg) 60 49% 50 43% 40 33% Mortality (%) 30 20% 20 11% 10 Hospital stay 60 days 180 days 1 year 2 years Connors AF Jr et al. Am J Respir Crit Care Med. 1996;154:959-67

28 Total costs (€ billion) of respiratory diseases in Europe in 2000

29 Piano sanitario nazionale

30 Trend dell’asma negli adulti in ulteriore aumento in parecchie nazioni
ASTHMA PREVALENCE IN ADULTS:GOOD NEWS? Weiland and Pearce Editorial Thorax 2004 THE EPIDEMIC HAS ENDED,OR HAS IT ? Shafazand and Colice Editorial Chest 2004 THE PREVALENCE OF ASTHMA IS NO LONGER INCREASING IN SOME COUNTRIES Anderson BMJ 2005 Trend dell’asma negli adulti non in ulteriore aumento in parecchie nazioni

31 Chinn,Jarvis, Burney,Cerveri et al Thorax 2004
INCREASE IN DIAGNOSED ASTHMA BUT NOT IN SYMPTOMS IN THE EUROPEAN COMMUNITY RESPIRATORY HEALTH SURVEY Chinn,Jarvis, Burney,Cerveri et al Thorax 2004

32 ** * NET CHANGE IN IN PREVALENCE ( per 10 years of follow-up) OF
SYMPTOMS, DIAGNOSED ASTHMA, AND CURRENT MEDICATION IN THE ECRHS Net change (%) Wheeze without a cold Woken with chest tightness Woken with shortness of breath Current medication “Diagnosed asthma” Attack of asthma ** * Chinn, Cerveri and ECRHS group Thorax 2004 * p = ** p<0.001

33 INCREASE IN DIAGNOSED ASTHMA BUT NOT IN SYMPTOMS IN THE ECRHS
“…. Either increased use of effective treatments has led to decreased morbidity among asthmatic subjects or those with mild disease have become more likely to label themselves as asthmatic” Chinn, Cerveri and ECRHS group Thorax 2004

34 NET CHANGE IN PREVALENCE ( per 10 years of follow-up)
OF DIAGNOSED ASTHMA AND NASAL RHINITIS IN THE ECRHS (11169 subjects ) PREVALENCE IN ECRHS I: 24% PREVALENCE IN ECRHS I: 26% PREVALENCE IN ECRHS I: 26% PREVALENCE IN ECRHS I: 5% Chinn, Cerveri and ECRHS group Thorax 2004

35 INCREASE IN DIAGNOSED ASTHMA BUT NOT IN SYMPTOMS IN THE ECRHS
“….An increase in reported nasal allergies was observed that was greater in the youngest age group. It is not possible to be certain whether it is explained by biological changes occurring at particular ages or by factors occurring earlier in life that make this younger cohort more suceptible.. ” Chinn, Cerveri and ECRHS group Thorax 2004

36 Anti-asthmatic treatment
ASTHMA ATTACKS AND ANTI-ASTHMATIC TREATMENT IN ITALY (1993 AND 2000) Asthma attacks Anti-asthmatic treatment 3.6% 3.2% 2.5% 1.9% Verlato,Cerveri et al, J Allergy Clin Immunol 2003

37 NASAL ALLERGIES IN ITALY (1993 AND 2000)
18.3% 15.4% P < 0.001 Nasal allergies

38 CONCLUSIONI Non aumento in Italia di attacchi di asma negli anni 90
Nuovi farmaci, miglior strategia globale di trattamento, di accesso alle strutture sanitarie e di controllo degli allergeni “indoor” determinanti di una minore espressione della malattia Ancora attenzione particolarmente focalizzata alla rinite allergica

39 EPIDEMIOLOGIA DELL’ASMA
Stabilizzazione dovuta al miglioramento dei trattamenti antiasmatici Plateau per raggiunto sviluppo della patologia in tutti i soggetti “suscettibili” (“Saturation”: massimo effetto del cambiamento dell’esposizione ambientale negli individui suscettibili)

40 About 60 % of asthmatics reported AR
ALLERGIC RHINITIS AND ASTHMA COMORBIDITY IN A SURVEY OF YOUNG ADULTS IN ITALY About 60 % of asthmatics reported AR Subjects with AR had eightfold risk of having asthma compared to subjects without AR Bugiani and ECRHS group, Allergy 2005

41 Tumor necrosis factor polymorphisms and asthma
in two international population-based cohorts ( ECRHS and SAPALDIA studies) ECRHS SAPALDIA Age 18-44 All ages Subjects (number) 3659 3572 6071 Gender (% males) 48 50 Mean age (years ± SD) 34±7 33±8 41±11 Asthma Symptoms (%) 3.7 2.92 2.89 Physician diagnosed asthma 6.55 6.19 6.2 Atopy 22.52 18.11 16.2 Castro Giner, ECRHS and Sapaldia groups AJRCCM, submitted

42 ASTHMA SEVERITY IN THE GENERAL POPULATION According to GINA 2006 Classification (ECRHS II; ) de Marco ECRHS group JACI 2006

43 Accordini, Cerveri and ECRHS group
THE BURDEN OF ASTHMA REMAINS SUBSTANTIAL IN EUROPE A DECADE AFTER THE GINA GUIDELINES (ECRHS II; ) 13.2% Light burden 14% Heavy burden 72.8% No burden No burden no productivity losses no use of hospital services Light burden up to 12 lost working days or up to 3 days per months limited Heavy burden > 12 lost working days or > 3 days per months limited or use of hospital services Accordini, Cerveri and ECRHS group Allergy 2007

44 Accordini, Cerveri and ECRHS group
THE BURDEN OF ASTHMA REMAINS SUBSTANTIAL IN EUROPE A DECADE AFTER THE GINA GUIDELINES (ECRHS II; ) Light burden up to 12 lost working days or up to 3 days per months limited no use of hospital services Heavy burden > 12 lost working days or > 3 days per months limited or use of hospital services FEV1 % predicted Accordini, Cerveri and ECRHS group Allergy 2007

45 REAL-WORLD EVALUATION OF ASTHMA CONTROL AND TREATMENT(REACT): Findings from a national Web-based survey (1812 patients with moderate to severe asthma using standard asthma medications) 55% Uncontrolled asthma 45% Controlled asthma Peters et al JACI 2007

46 PREVALENCE OF ASTHMA TREATMENT ADHERENCE AT ECRHS I AND II
ECRHS II Prevalence of asthma treatment compliance in stable conditions Corsico,Cerveri and ECRHS group Resp Med 2007

47 Utilizzo farmaci R03 (antiasmatici) Bisogno terapeutico teorico
ITALIA CAMPANIA EMILIA LOMBARDIA Dati Fondazione SKF DDD = dose media mantenimento giornaliera

48


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