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

2 Vision: Healthy People in Healthy CommunitiesVision: Healthy People in Healthy Communities Mission: To protect health, prevent disease, and promote health and well-beingMission: To protect health, prevent disease, and promote health and well-being Departmental Stats:Departmental Stats: –Annual budget over $850 million –Nearly 4,000 employees Los Angeles County Department of Public Health

How Many Persons in Los Angeles County Are Currently Living with COPD? 2005 LA County Health Survey: Have you ever been told by a doctor that you have a chronic respiratory condition, such as emphysema or chronic bronchitis, that lasted 3 months or longer? - 300,000 (4.0%) 2005 CHIS: Have you ever been told that you have lung disease other than asthma? - 105,000 (1.4%) 2011 BRFSS: Have you ever been told by a doctor or health professional that you have COPD, emphysema or chronic bronchitis? - 197,000 (3.1%) 2. Source: 2005 California Health Interview Survey. 3

Age-adjusted rate/100,000 Cause of Death % Change from 2001 Coronary heart disease % Stroke % Lung cancer % COPD % Alzheimer’s disease % Pneumonia & influenza % Diabetes % Colorectal cancer % Chronic liver disease12 0% Breast cancer (female) % Source: Office of Health Assessment and Epidemiology, Los Angeles County Department of Public Health Trends in the Leading Causes of Death Los Angeles County,

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

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

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

California a Leader in Tobacco Control 8 First state to pass a tobacco tax (1988), though we have since fallen behind—the tobacco tax rate in California is now below the national average: ─California’s tax rate $0.87 vs. U.S. average of $1.53 (NY’s is $4.35) Smoke-free workplace law (1995) Smoke-free restaurant law (1995) Smoke-free bar law (1998) Hard-hitting counter-advertising campaigns

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

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

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

Smoking Cessation Ask, Advise, and Refer No Butts ( ) California Smokers' Helpline is a telephone program that can help persons quit smoking. Helpline services are free and are offered in English, Spanish, Cantonese, Vietnamese, Korean, and TTY/TDD. LA County’s website, provides additional information and tips for living tobacco-free. 12

Trends in COPD Mortality Source: CDC, National Center for Health Statistics 13

Trends in Lung Cancer Mortality Source: CDC, National Center for Health Statistics 14

Health Impacts of Air Pollution in Southern California (per year) Data Source: South Coast Air Quality Management District, 2010, 15

16 Ozone Trends: Los Angeles County Source:

17 PM 2.5 Trends: Los Angeles County Source:

Reducing Near-Roadway Exposures CARB advisory, avoid siting new sensitive land uses within 500 ft of a freeway, urban roads with 100,000 vehicles/day, or rural roads with 50,000 vehicles per day - "sensitive land uses" include residences, schools, child care centers, playgrounds, and medical facilities -is voluntary ("Land use agencies have to balance other considerations, including housing and transportation needs, economic development priorities, and other quality of life issues.") 18

Broader Policy Action Needed Stronger mandates for use of zero emission and low emission vehicles, including trucks used for goods movement Alternative goods movement strategies Establish regulatory standards for near roadway emissions Increase mass transit options Promote land use practices that reduce auto dependence 19

20 Opportunities in the Health Reform Era Landmark policy changes provide new opportunities for prevention, early detection and treatment:   Expanded access to coverage   No-cost preventive services   Primary care medical homes   Increased accountability for outcomes We must maximize those opportunities given the: – –growth of our aging population (in LA County, people aged 65+ are projected to grow from 1.1 million in 2010, to 2.2 million in ); – –persistence of health inequities; and – –burden of COPD and other chronic conditions. 1) Kao, DT & Lloyd, DA. Los Angeles Population Change and Healthy Aging. Los Angeles, CA: USC Roybal Institute on Aging, 2010

Prevention Opportunities from Community Transformation Grant Funding period: 2012 to 2017 Funding amount: $49 million – –Active Living & Healthy Eating e.g. active transportation, school meals, sugar sweetened beverage consumption – –Tobacco Free Living e.g. nicotine addiction screening, smoking cessation services ─ ─High Impact Clinical & Other Preventive Services e.g. blood pressure screenings, aspirin use screenings ─ ─Health Marketing e.g. paid media placements, social media, and public education through print materials 21

Several Key Affordable Care Act Provisions Several Key Affordable Care Act Provisions Section 3025 of ACA requires Centers for Medicare and Medicaid Services (CMS) to reduce payments to Inpatient Prospective Payment System (IPPS) hospitals with excess readmissions. In Fiscal Year 2015, CMS is finalizing the expansion of the applicable conditions to include patients admitted for an acute exacerbation of COPD. The ACA supports comparative effectiveness research by establishing a non-profit Patient-Centered Outcomes Research Institute (PCORI). PCORI will help identify clinically effective COPD treatments and diagnostic tests. 22

Additional Potential Benefits of ACA for Persons with COPD Insurance companies may not drop patients due to an illness or condition nor exclude patients based on pre-existing conditions More support available for preventive services, including smoking cessation Emphasis on primary care medical homes and increased coordination between care providers; use of electronic medical records to support care coordination 23

Major Actions Needed Enhanced surveillance to better characterize the toll of COPD and assess the effectiveness of prevention and treatment efforts moving forward Improved systems of care to increase early detection and linkage to high-quality medical services. Improved coordination of medical and other support services. Continued focus on community-based prevention—tobacco control, air pollution reduction, workplace protection. Increased investment in research to identity more effective treatments and prevention strategies 24