TRENDS IN CHRONIC BRONCHITIS AND EMPHYSEMA: MORBIDITY AND MORTALITY

Transcription

1 TRENDS IN CHRONIC BRONCHITIS AND EMPHYSEMA: MORBIDITY AND MORTALITY AMERICAN LUNG ASSOCIATION EPIDEMIOLOGY & STATISTICS UNIT RESEARCH AND SCIENTIFIC AFFAIRS MARCH 2003

2 TABLE OF CONTENTS Trends in Chronic Bronchitis and Emphysema Morbidity and Mortality Introduction COPD Mortality, , COPD Prevalence, and COPD Hospital Discharges, Economic Cost of COPD Glossary and References List of Tables Table 1: Number of Deaths by Race and Sex, , Table 2: Age Adjusted Mortality Rate by Race and Sex per 100,000 Population, , Table 3: COPD - Number of Deaths and Age-Adjusted Death Rate per 100,000 Population by Ethnicity and Sex, Table 4: Chronic Bronchitis - Number of Conditions and Age-Specific Prevalence Rates per 1,000 Persons, , Table 5: Chronic Bronchitis - Number of Conditions and Rate per 1,000 Persons by Race and Age, , Table 6: Chronic Bronchitis - Number of Conditions and Rate per 1,000 Persons by Sex, , Table 7: Emphysema - Number of Conditions and Age-Specific Prevalence Rates per 1,000 Persons, , Table 8: Emphysema - Number of Conditions and Rate per 1,000 Persons by Race and Age, , Table 9: Emphysema Number of Conditions and Rate per 1,000 Persons by Sex, , Table10: Chronic Bronchitis and Emphysema - Number of Conditions and Prevalence Rate per 1,000 Persons by Ethnicity, Table11: Number of First-Listed Hospital Discharges and Rate per 10,000 Population by Age, Table12: Number of First-Listed Hospital Discharges and Rate per 10,000 Population by Race, Table13: Number of First-Listed Hospital Discharges and Rate per 10,000 Population by Sex, List of Figures Figure 1: Age-Adjusted Death Rates Based on 1940 and 2000 Standard Populations, Figure 2: Number of Conditions in Adults Aged 18 Years and Older, Figure 3: Percentage Distribution of Chronic Bronchitis by Sex, Age, Ethnicity and Geographic Region, 2001 Figure 4: Percentage Distribution of Emphysema by Sex, Age, Ethnicity & Geographic Region, 2001 Figure 5: Trend in Hospitalizations, Figure 6: Trend in Hospitalizations by Age, Figure 7: COPD - Trend in Hospitalizations by Race, Figure 8: COPD - Trend in Hospitalizations by Sex,

3 Introduction The following tables delineate information available from national surveys and statistics on trends in morbidity and mortality attributed to chronic obstructive pulmonary disease (COPD). COPD is used as an umbrella term for chronic bronchitis and emphysema. As an overview of the COPD problem in the United States, data are examined on hospitalization, prevalence, mortality and economic costs. Please note that the following tables and narrative refer exclusively to data on chronic bronchitis, emphysema and other chronic lower respiratory diseases; data on asthma are not included. COPD Mortality Beginning with 1999 mortality data, the population standard used for calculating age-adjusting death rates was changed from the 1940 population to the 2000 population. This change had three important outcomes: (i) provided age-adjusted rates that are less divergent from crude rates (ii) ensured that all government agencies use the same standard and (iii) corrected the public perception that age adjustment to the 1940 population provides out-of-date statistics. Use of the 2000 standard has placed more weight on death rates at older ages and less weight on death rates at younger ages. Because most lung disease rates increase with age, death rates using the new standard are higher than those using the old standard. Figure 1 compares the COPD age-adjusted death rates based on the 1940 and 2000 standard populations from Age-adjusted deaths rates for COPD are approximately 2 times greater using the 2000 standard population than those based on the 1940 standard population. In addition, starting with 1999 data, the tenth revision of International Classification of Diseases (ICD-10) has replaced ICD-9 in coding and classifying mortality data from death certificates. The ICD is periodically revised to incorporate changes in the medical field. This change has several consequences: (i) new cause-of death titles and corresponding cause-of-death codes, i.e. ICD-10 has alphanumeric categories rather than numeric categories, (ii) breaks in comparability of cause-ofdeath statistics, and (iii) restructuring of the leading causes of deaths. In order to assess the net effect of the new revision on death statistics, a comparability ratio is derived. The comparability ratio is calculated by dividing the number of deaths for a selected cause of death classified by the new revision by the number of deaths classified to the most nearly comparable cause of death by the previous revision. A comparability ratio of 1 denotes no change between revisions; a ratio of less than 1 signifies a decrease and a ratio of greater than 1 symbolizes an increase in deaths. The comparability ratio for COPD is 1.056, indicating a 6% increase in assignments of deaths due to COPD when using ICD-10. Sex and Race Specific Mortality Rates Due to decennial revisions of the International Classification of Diseases (ICD) coding system and the change in age-adjusted standard population, the number and rate of COPD deaths for are not directly comparable to those reported from Table 1 documents the number of deaths by race and sex between 1979 and In 2000, 117,522 people died of COPD. Specifically, 16,700 died of emphysema, 1,167 people died from chronic bronchitis and 99,655 people died from chronic obstructive pulmonary disease not classified elsewhere. For the first time the number of deaths due to COPD in 2000 was higher among women than in men.

4 Table 2 displays the age-adjusted death rate per 100,000 population by race and sex. COPD is the fourth-ranked cause of death in the United States with an age-adjusted death rate of 42.7 per 100,000 population. The age adjusted death rate in males was 1.5 times greater than the rate seen in females. The age-adjusted death rate in whites (44.8 per 100,000) was 1.6 times greater than the rate in blacks (27.8 per 100,000). COPD is, as of now, the only lung disease in which the white population has higher age-adjusted death rates than blacks. Black women had the lowest age-adjusted death rates in 2000 with 18.9 per 100,000. Table 3 delineates the number of deaths and mortality rate per 100,000 population by Hispanic origin. In 2000, 2,397 Hispanics died of COPD a mortality rate of 7.6 per 100,000 population. Rates in Hispanics were significantly lower than other ethnic groups. Unlike morbidity estimates, which are drawn from sample populations and extrapolated to the overall population, mortality data is obtained from the general population by death certificates. Therefore, the sex- and race-specific numbers and rates denote true differences, not estimates. Prevalence Trends, , The National Health Interview Survey (NHIS) is a multi-purpose health survey conducted by the National Center for Health Statistics (NCHS), Centers for Disease Control and Prevention (CDC). It is the principal source of information on the health of the civilian, noninstitutionalized, household population of the U.S. Despite the periodic revision of the NHIS Core questionnaire, Supplements began to play an increasingly important role in the survey as a means of enhancing topic coverage in the Core section. The unintended result was an increasingly unwieldy survey instrument and longer interviewing sessions: recent questionnaires (Core and Supplements combined) ran almost 300 pages, while the interviews averaged two hours. This imposed an unacceptable burden on NCHS staff, US Bureau of Census interviewers, the data collection budget, and on the NHIS respondents. Furthermore, the excessive length of NHIS interviews contributed to declines in both response rate and data quality. For all these reasons, NCHS implemented a redesigned NHIS questionnaire in The new questionnaire design has made it impossible to compare current chronic bronchitis and emphysema estimates with those prior to 1997 and to each other. Survey respondents were formerly asked if any family member had chronic bronchitis and/or emphysema in the past 12 months (point prevalence). After the 1997 revision, respondents are asked if they had been diagnosed with chronic bronchitis in the past 12 months (point prevalence) and if they had ever been told by a health professional that they had emphysema (period prevalence). In contrast with the prior questionnaire, the redesigned survey measures physician-diagnosed chronic bronchitis and emphysema and produces a more specific estimate than self-report. In addition, the change to the emphysema question will increase estimates but will reflect the true prevalence of the disease since it is incurable. Moreover, since children historically do not suffer from COPD, these questions have been removed from the child questionnaire. Data between 1982 and 1996 should not be compared to estimates.

5 COPD Figure 2 displays the number of COPD conditions in adults 18 years of age and older from 1997 to In 2001, 13.3 million U.S. adults aged 18 years and older were estimated to have COPD. Chronic Bronchitis Table 4 displays age-specific prevalence estimates for chronic bronchitis. After seeing a 10 percent decline in chronic bronchitis prevalence rates between 1997 and 1999, the prevalence rate increased 24 percent from 1999 to In 2001, it was estimated that 11.2 million Americans reported a physician diagnosis of chronic bronchitis: 5 million year olds, 4 million year olds and 2.0 million people over 65. Those over 65 had the highest prevalence rate at 67.3 per 1,000 persons while those had the lowest rate estimated at 45.7 per 1,000 persons. Between 1997 and 2001, the prevalence rate among those in the age group increased 17 percent compared to a 9 and 10 percent increase in the and over 65 age groups, respectively. However, only the rate in the age group was significantly different than the others. Race specific trends are displayed in Table 5. Between 1997 and 2001, the prevalence rate in whites increased 14 percent, from 50.9 to 57.1 per 1,000 persons, while the rate in blacks increased 7 percent, from 48.9 to 52.5 per 1,000 persons. In 2001, 9.5 million whites and 1.2 million blacks were diagnosed with chronic bronchitis. The difference between races was not significant. The highest prevalence rate was in the over 65 population (68.9 per 1,000 persons) for whites and in the age group (75.0 per 1,000) for blacks. Table 10 displays the number of conditions and prevalence rates by Hispanic origin. Close to 700,000 Hispanic Americans (31.0 per 1,000 persons) were diagnosed with chronic bronchitis in The prevalence rate seen in Hispanics was significantly lower than that of Non-Hispanic whites and blacks. Sex specific prevalence trends are shown in Table 6. After a 16 percent decline in males in recent years, the prevalence rate increased 15 percent between 1999 and Females experienced a 9 percent increase between 1999 and 2001, after an 8 percent decrease between 1997 and In 2001, 3.7 million males and 7.5 million females were diagnosed with chronic bronchitis. The difference between the prevalence rates for males (38.0 per 1,000) and females (70.5 per 1,000) was statistically significant. Percentage Distribution of Conditions, 2001 The percentage distribution of chronic bronchitis is displayed in Figure 3. Four pie charts describe the distribution of chronic bronchitis by sex, age, ethnicity and geographic region. Emphysema Age specific prevalence trends are displayed in Table 7. The emphysema prevalence rate is very low in those under age 45. Of the estimated 3 million Americans ever diagnosed with emphysema, 93 percent were 45 or older. In 2001, the reported emphysema lifetime prevalence rate was 14.6 per

6 1,000, a 12 percent decrease from Rates in all age specific groups were statistically significant different from each other. Race specific prevalence trends are displayed in Table 8. The lifetime prevalence rate of emphysema increases with age in the white population. In 2001, the rate in whites over age 65 (53.9 per 1,000 persons) was almost 3 times greater than that in the population between 45 and 64 (19.0 per 1,000). The age specific prevalence rate in blacks is based on the reporting of much smaller numbers, which produces less reliable estimates and is therefore difficult to definitively characterize a clear trend. Between 1997 and 2001, the prevalence rate decreased by 8 percent in whites and decreased by 30 percent in blacks. The difference in the overall rate reported between whites (16.5 per 1,000) and blacks (7.0 per 1,000) was significant. Table 10 displays the number of conditions and prevalence rates by Hispanic origin. Over 130,000 Hispanic Americans (6.0 per 1,000 persons) have been diagnosed with emphysema. The prevalence rate seen in Hispanics was significantly lower than Non-Hispanic whites. Sex specific prevalence trends are delineated in Table 9. Between 1997 and 2001 the prevalence rate for emphysema decreased 15 percent in males and close to 6 percent in females. Men had a higher prevalence rate than females 17.2 per 1,000 persons vs per 1,000 persons. The difference between these rates was significant. Close to 1.7 million males and 1.3 million females have been diagnosed with emphysema in their lifetime. Percentage Distribution of Conditions, 2001 The percentage distribution of emphysema is displayed in Figure 4. Four pie charts describe the distribution of emphysema by sex, age, ethnicity and geographic region. COPD Hospital Discharges The trend in the overall hospital discharge rate for COPD is depicted in Figure 5. The first listed diagnosis is identified as the principal diagnosis on the medical record. An estimated 661,000 discharges were reported in 2000, a discharge rate of 23.8 per 10,000 population. Differences may exist between data reported for and earlier years because of the redesign of the survey in Also in 1992, a jump in hospital discharges occurred due to a change in the ICD code for chronic bronchitis. A new sub-classification (chronic bronchitis with acute exacerbations, ICD code ) was introduced. It appears that many discharges previously coded as acute bronchitis (ICD code 466) were coded as beginning in Thus the growth seen in 1992 probably does not reflect an increase in COPD morbidity but rather indicates an underestimation in previous years. Between 1992 and 2000 the overall discharge rate increased by 41 percent from 16.9 per 10,000 population to 23.8 per 10,000 population. This difference in rate was significant. Table 11 delineates the number of first-listed hospital discharges and hospital discharge rate by age between COPD is an important cause of hospitalization in our aged population. More than 65 percent of discharges were in the 65 years and older population in The discharge rate

7 for the population over age 65 (125.3 per 10,000) was significantly different than the rate for any other group. For instance, the rate in the over age 65 group was over four times higher than that in the age group (30.8 per 10,000). This trend is shown in Figure 6. The trend in hospital discharges by race is shown in Table 12 and Figure 7. The 2000 discharge rate for COPD was highest in whites (19.7 per 10,000). In blacks the rate was 13.9 per 10,000. The discharge rate in all other races was reported at 6.6 per 10,000. These rates however, should be used with caution due to the large percentage of discharges (23% in 2000) for which race was not reported. It appears that the number of hospital discharges in whites may be disproportionately underestimated, making it difficult to draw comparisons between races using these data. Table 13 displays the trend in COPD hospital discharges by sex. Between 1988 and 1992, males had slightly higher rates than females. Since 1993, the rate in females has surpassed the rate for males. In 2000 the rates among males and females were 22.1 per 10,000 and 25.1 per 10,000, respectively. The difference between sexes was not significant. This trend is also shown in Figure 8. Economic Costs Chronic bronchitis and emphysema take a heavy toll on our economy. According to estimates made by the National Heart Lung and Blood Institute, in 2002 the annual cost to the nation for COPD was $32.1 billion. This included $18.0 billion in direct health care expenditures, $6.8 billion in indirect morbidity costs and $7.3 billion in indirect mortality costs. Summary COPD is a major cause of morbidity and mortality in the United States. An estimated 13.3 million adults aged 18 and over have reported a physician diagnosis of COPD. However, a recent survey found that 24 million U.S. adults have some evidence of impaired lung function, indicating an under diagnosis of the disease. 1 COPD is the fourth leading cause of death and for the first time the number of women dying from the disease has surpassed the number seen in men. 1 National Center for Health Statistics. National Health & Nutrition Examination Survey,

8 GLOSSARY Prevalence: Period Prevalence: Point Prevalence: Crude Rate: Age-Adjusted Rate: The number of existing cases of a particular condition, disease, or other occurrence (e.g.., persons smoking) at a given time. The proportion of cases that exist within a population at any point during a specified period of time. The proportion of cases that exist within a population at a single point in time. Cases in a particular population quantity- e.g., per hundred. A figure that is statistically corrected to remove the distorting effect of age when comparing populations of different age structures. REFERENCES 1. National Center for Health Statistics, Raw Data from the National Health Interview Survey, United States, (Analysis by the American Lung Association Research and Scientific Affairs Division, Using SPSS and SUDDAN software) 2. National Center for Health Statistics, Current Estimates of the National Health Interview Survey, United States, selected years, National Center for Health Statistics, Report of Final Mortality Statistics, National Center for Health Statistics, Summary: National Hospital Discharge Survey, and data provided upon special request to the NCHS. 5. National Center for Health Statistics, Underreporting of Race in the National Hospital Discharge Survey, July National Heart Lung and Blood Institute, Morbidity and Mortality Chartbook on Cardiovascular, Lung and Blood Diseases, 2002.

9 TABLE 1: COPD - NUMBER OF DEATHS BY RACE AND SEX , (1) ALL OTHER (2) TOTAL WHITE TOTAL BLACK BOTH BOTH BOTH BOTH YEAR SEXES MALE FEMALE SEXES MALE FEMALE SEXES MALE FEMALE SEXES MALE FEMALE 1979 (3) 47,335 34,162 13,173 44,597 32,044 12,553 2,738 2, ,487 1, ,159 37,333 15,826 50,084 34,969 15,115 3,075 2, ,823 2, ,778 38,486 17,292 52,556 36,014 16,542 3,222 2, ,941 2, ,715 38,388 18,327 53,437 35,987 17,450 3,278 2, ,984 2, ,685 41,664 21,021 58,958 38,894 20,064 3,727 2, ,336 2, ,536 42,546 22,990 61,497 39,622 21,875 4,039 2,924 1,115 3,592 2, ,782 45,045 25,737 66,412 41,934 24,478 4,370 3,111 1,259 3,881 2,783 1, ,604 45,474 27,130 68,086 42,163 25,923 4,518 3,311 1,207 4,028 2,942 1, ,020 45,309 28,711 69,341 42,046 27,295 4,679 3,263 1,416 4,132 2,891 1, ,256 47,117 31,139 73,200 43,528 29,672 5,056 3,589 1,467 4,464 3,184 1, ,475 46,330 33,145 74,120 42,694 31,426 5,355 3,636 1,719 4,687 3,159 1, ,860 47,531 34,329 76,483 43,876 32,607 5,377 3,655 1,722 4,669 3,168 1, ,544 48,558 36,986 80,036 44,928 35,108 5,508 3,630 1,878 4,773 3,149 1, ,974 48,596 38,378 81,442 44,993 36,449 5,532 3,603 1,929 4,821 3,136 1, ,910 52,443 43,467 89,705 48,428 41,277 6,205 4,105 2,190 5,323 3,448 1, ,141 51,628 44,513 89,939 47,734 42,205 6,202 3,894 2,308 5,325 3,332 1, ,262 51,859 45,403 90,869 47,866 43,003 6,393 3,993 2,400 5,420 3,379 2, ,360 52,410 47,950 93,779 48,396 45,383 6,581 4,014 2,567 5,599 3,388 2, ,595 53,998 49,597 96,768 49,801 46,967 6,827 4,197 2,630 5,708 3,468 2, ,146 55,018 52, ,114 50,806 49,308 7,032 4,212 2,820 5,915 3,503 2, (4) 119,524 60,795 58, ,407 55,954 55,453 8,117 4,841 3,276 6,770 4,019 2, (4) 117,522 58,372 59, ,696 53,759 55,937 7,826 4,613 3,213 6,449 3,757 2,692 SOURCE: NATIONAL CENTER FOR HEALTH STATISTICS, MONTHLY VITAL STATISTICS REPORT, , (1) THIS TABLE REFERS EXCLUSIVELY TO DATA ON CHRONIC BRONCHITIS, EMPHYSEMA AND OTHER LOWER CHRONIC OBSTRUCTIVE PULMONARY DISEASES INCLUDING BRONCHIECTASIS. DATA ON ASTHMA ARE NOT INCLUDED. (2) ALL RACES OTHER THAN WHITE. (3) INTERNATIONAL CLASSIFICATION OF DISEASES, 9TH REVISION (ICD-9) CODE , (4) INTERNATIONAL CLASSIFICATION OF DISEASES, 10TH REVISION (ICD-10) CODE J40-J44, J47.

10 TABLE 2: COPD - AGE-ADJUSTED MORTALITY RATE BY RACE AND SEX PER 100,000 POPULATION, , (1,2,3) ALL OTHER (4) TOTAL WHITE TOTAL BLACK BOTH BOTH BOTH BOTH YEAR SEXES MALE FEMALE SEXES MALE FEMALE SEXES MALE FEMALE SEXES MALE FEMALE 1979 (5) (6) (6) SOURCE: NATIONAL CENTER FOR HEALTH STATISTICS, MONTHLY VITAL STATISTICS REPORT, , (1) THIS TABLE REFERS EXCLUSIVELY TO DATA ON CHRONIC BRONCHITIS, EMPHYSEMA AND OTHER LOWER CHRONIC OBSTRUCTIVE PULMONARY DISEASES INCLUDING BRONCHIECTASIS. DATA ON ASTHMA ARE NOT INCLUDED. (2) RATES FOR THE YEARS ARE AGE-ADJUSTED TO THE 1940 U.S. STANDARD POPULATION. (3) RATES FOR ARE AGE-ADJUSTED TO THE 2000 U.S. STANDARD POPULATION. (4) ALL RACES OTHER THAN WHITE. (5) INTERNATIONAL CLASSIFICATION OF DISEASES, 9TH REVISION (ICD-9) CODE , (6) INTERNATIONAL CLASSIFICATION OF DISEASES, 10TH REVISION (ICD-10) CODE J40-J44, J47.

11 TABLE 3: COPD-NUMBER OF DEATHS AND DEATH RATE PER 100,000 POPULATION BY ETHNIC ORIGIN AND SEX, (1,2) BOTH SEXES MALE FEMALE ORIGIN NUMBER RATE NUMBER RATE NUMBER RATE NUMBER RATE NUMBER RATE NUMBER RATE TOTAL 117, , , , , , HISPANICS 2, , , , , , NON HISPANIC (3) 114, , , , , , NON HISPANIC WHITE 107, , , , , , NON HISPANIC BLACK 6, , , , , , SOURCE: NATIONAL CENTER FOR HEALTH STATISTICS, FINAL MORTALITY STATISTICS REPORT, (1) THIS TABLE REFERS EXCLUSIVELY TO DATA ON CHRONIC BRONCHITIS, EMPHYSEMA AND OTHER LOWER CHRONIC OBSTRUCTIVE PULMONARY DISEASES INCLUDING BRONCHIECTASIS. DATA ON ASTHMA ARE NOT INCLUDED. (2) INTERNATIONAL CLASSIFICATION OF DISEASES, 10TH REVISION (ICD-10) CODE J40-J44, J47. (3) INCLUDES RACES OTHER THAN WHITE AND BLACK.

12 TABLE 4: CHRONIC BRONCHITIS - NUMBER OF CONDITIONS AND AGE-SPECIFIC PREVALENCE RATES PER 1,000 PERSONS, , AGE GROUP TOTAL (1) < YEAR NUMBER RATE NUMBER RATE NUMBER RATE NUMBER RATE NUMBER RATE ,709, ,110, ,324, ,954, ,320, ,864, ,711, ,667, ,976, ,510, ,925, ,097, ,881, ,283, ,664, ,618, ,483, ,022, ,415, ,697, ,379, ,987, ,690, ,049, ,652, ,749, ,927, ,125, ,561, ,136, ,894, ,453, ,024, ,558, ,859, ,974, ,235, ,641, ,476, ,622, ,584, ,447, ,365, ,674, ,098, ,549, ,480, ,938, ,542, ,589, ,494, ,561, ,962, ,828, ,143, ,820, ,997, ,845, ,048, ,930, ,021, ,873, ,047, ,223, ,878, ,533, ,789, ,422, ,305, ,018, ,150, ,087, ,904, ,142, ,017, (2,3) 9,667, NA NA 4,491, ,050, ,125, (2,3) 8,977, NA NA 3,825, ,117, ,033, (2,3) 8,847, NA NA 3,978, ,962, ,907, (2,3) 9,354, NA NA 3,876, ,353, ,125, (2,3) 11,198, NA NA 4,913, ,073, ,211, SOURCE: NATIONAL CENTER FOR HEALTH STATISTICS, NATIONAL HEALTH INTERVIEW SURVEY, , (1) DUE TO ROUNDING, NUMBERS ACROSS MAY NOT SUM TO THE TOTAL. (2) IN 1997, THE NATIONAL HEALTH INTERVIEW SURVEY COMPLETELY REDESIGNED THEIR QUESTIONNAIRE. THEREFORE, ESTIMATES PRIOR TO 1997 CANNOT BE COMPARED WITH LATER ESTIMATES. (3) THE REVISED QUESTIONNAIRE NOW ASKS RESPONDENTS ABOUT CHRONIC BRONCHITIS DIAGNOSIS OVER THE PAST 12 MONTHS. STARTING IN 1997 ESTIMATES ON CHILDREN UNDER 18 HAVE BEEN ELIMINATED. OVERALL ESTIMATES WILL BE SMALLER.

13 TABLE 5: CHRONIC BRONCHITIS - NUMBER OF CONDITIONS AND RATE PER 1,000 PERSONS BY RACE AND AGE, , WHITE UNDER ALL AGES YEAR NUMBER RATE NUMBER RATE NUMBER RATE NUMBER RATE NUMBER RATE ,848, NA NA 1,704, ,224, ,776, ,667, NA NA 1,766, ,470, ,903, ,281, NA NA 2,021, ,583, ,885, ,627, NA NA 2,152, ,649, ,428, ,857, NA NA 1,901, ,562, ,320, ,118, NA NA 2,298, ,942, ,358, ,501, NA NA 2,259, ,720, ,480, ,891, NA NA 2,275, ,539, ,705, ,022, NA NA 2,409, ,976, ,407, ,322, NA NA 2,228, ,503, ,503, ,417, NA NA 2,491, ,000, ,908, ,693, NA NA 2,660, ,790, ,143, ,800, NA NA 3,077, ,691, ,568, ,965, NA NA 2,875, ,811, ,651, ,348, NA NA 2,810, ,812, ,970, ,2 NA NA 3,833, ,526, ,923, ,283, ,2 NA NA 3,246, ,743, ,888, ,878, ,2 NA NA 3,408, ,493, ,747, ,649, ,2 NA NA 3,277, ,845, ,934, ,056, ,2 NA NA 4,080, ,411, ,996, ,488, BLACK UNDER ALL AGES YEAR NUMBER RATE NUMBER RATE NUMBER RATE NUMBER RATE NUMBER RATE , NA NA 202, * 84, * 801, , NA NA 182, * 39, * 920, , NA NA 182, * 57, * 872, , NA NA 263, , * 1,093, , NA NA 95, * 65, * 819, , NA NA 190, , * 1,111, , NA NA 240, , * 1,159, , NA NA 153, , * 996, , NA NA 264, , * 1,044, , NA NA 275, , * 1,251, , NA NA 241, , * 1,231, , NA NA 324, , * 1,432, , NA NA 108, * 123, * 1,056, , NA NA 311, , * 1,414, ,290, NA NA 280, * 102, * 1,672, ,2 NA NA 522, , , ,083, ,2 NA NA 427, , , , ,2 NA NA 393, , , , ,2 NA NA 388, , , , ,2 NA NA 580, , , ,232, SOURCE: NATIONAL CENTER FOR HEALTH STATISTICS, NATIONAL HEALTH INTERVIEW SURVEY * ESTIMATE FOR WHICH THE NUMERATOR HAS A RELATIVE STANDARD ERROR OF MORE THAN 30 PERCENT. NA: NOT AVAILABLE (1) IN 1997, THE NATIONAL HEALTH INTERVIEW SURVEY COMPLETELY REDESIGNED THEIR QUESTIONNAIRE. THEREFORE, ESTIMATES PRIOR TO 1997 CANNOT BE COMPARED WITH LATER ESTIMATES. ( ) PAST 12 MONTHS. STARTING IN 1997 ESTIMATES ON CHILDREN UNDER 18 HAS BEEN ELIMINATED. OVERALL ESTIMATES WILL BE SMALLER.

14 TABLE 6: CHRONIC BRONCHITIS - SEX-SPECIFIC NUMBER OF CASES AND PREVALENCE RATE PER 1,000 PERSONS, , CHRONIC BRONCHITIS MALE FEMALE YEAR NUMBER RATE NUMBER RATE ,438, ,271, ,645, ,218, ,180, ,745, ,326, ,293, ,708, ,671, ,276, ,473, ,763, ,130, ,446, ,528, ,841, ,743, ,160, ,389, ,359, ,135, ,676, ,144, ,624, ,396, ,587, ,945, ,049, ,101, ,094, ,573, ,767, ,209, ,661, ,186, ,013, ,341, ,718, ,479, SOURCE: NATIONAL CENTER FOR HEALTH STATISTICS, NATIONAL HEALTH INTERVIEW SURVEY, , (1) IN 1997, THE NATIONAL HEALTH INTERVIEW SURVEY REDESIGNED THEIR QUESTIONNAIRE. THEREFORE, ESTIMATES PRIOR TO 1997 CANNOT BE COMPARED WITH LATER ESTIMATES. (2) THE REVISED QUESTIONNAIRE NOW ASKS RESPONDENTS ABOUT CHRONIC BRONCHITIS DIAGNOSIS OVER THE PAST 12 MONTHS. STARTING IN 1997, ESTIMATES ON CHILDREN UNDER 18 HAS BEEN ELIMINATED. OVERALL ESTIMATES WILL BE SMALLER.

15 TABLE 7: EMPHYSEMA - NUMBER OF CONDITIONS AND AGE SPECIFIC PREVALENCE RATES PER 1,000 PERSONS, , AGE GROUP TOTAL (1) < YEAR NUMBER RATE NUMBER RATE NUMBER RATE NUMBER RATE NUMBER RATE ,325, * 180, * 1,122, ,023, ,038, * 110, * 911, ,017, ,184, * 118, * 956, ,110, ,075, * 161, * 676, ,238, ,998, * 74, * 822, ,101, ,037, * 101, * 761, ,174, ,905, * 64, * 764, ,077, ,993, , * 123, * 795, ,062, ,017, * 70, * 595, ,352, ,646, * 64, * 602, , ,915, * 122, * 727, ,066, ,931, , * 179, * 775, , ,028, * 117, * 497, ,413, ,870, * 127, * 671, ,072, ,821, * 90, * 701, ,030, , 3 3,217, NA NA 284, * 1,228, ,704, , 3 2,959, NA NA 272, * 1,058, ,628, ,3 2,798, NA NA 224, * 936, ,637, , 3 3,124, NA NA 256, * 1,141, ,727, ,3 2,983, NA NA 200, * 1,099, ,683, SOURCE: NATIONAL CENTER FOR HEALTH STATISTICS, NATIONAL HEALTH INTERVIEW SURVEY, (1) DUE TO ROUNDING, NUMBERS ACROSS MAY NOT SUM UP TO TOTALS. (2) IN 1997, THE NATIONAL HEALTH INTERVIEW SURVEY COMPLETELY REDESIGNED THEIR QUESTIONNAIRE. THEREFORE, ESTIMATES PRIOR TO 1997 CANNOT BE COMPARED WITH LATER ESTIMATES. (3) THE REVISED QUESTIONNAIRE NOW ASKS RESPONDENTS ABOUT EMPHYSEMA DIAGNOSIS OVER THEIR LIFETIME. THEREFORE, OVERALL ESTIMATES WILL BE HIGHER. * ESTIMATES FOR WHICH THE NUMERATOR HAS A RELATIVE STANDARD ERROR (RSE) OF GREATER THAN 30 PERCENT. -- NO CASES IN SAMPLE. NA- NOT AVAILABLE.

16 TABLE 8: EMPHYSEMA - NUMBER OF CONDITIONS AND RATE PER 1,000 PERSONS BY RACE AND AGE, , ,2 WHITE UNDER ALL AGES YEAR NUMBER RATE NUMBER RATE NUMBER RATE NUMBER RATE NUMBER RATE , * NA NA 1,059, , ,209, , * NA NA 851, , ,908, , * NA NA 907, ,035, ,047, , * NA NA 626, ,182, ,942, , * NA NA 774, , ,847, , * NA NA 732, ,118, ,945, , * NA NA 705, ,013, ,771, , * NA NA 743, ,021, ,896, , * NA NA 557, ,236, ,863, , * NA NA 544, , ,555, , * NA NA 675, ,035, ,818, , NA NA 684, , ,730, , * NA NA 464, ,350, ,918, , * NA NA 643, , ,748, , * NA NA 623, ,004, ,685, ,2 NA NA 237, ,090, ,590, ,918, ,2 NA NA 237, , ,503, ,709, ,2 NA NA 197, , ,543, ,619, ,2 NA NA 223, ,037, ,601, ,863, ,2 NA NA 163, ,009, ,559, ,732, BLACK UNDER ALL AGES YEAR NUMBER RATE NUMBER RATE NUMBER RATE NUMBER RATE NUMBER RATE * NA NA 52, * 40, * 92, , * NA NA 60, * 38, * 130, * NA NA 49, * 75, * 124, * NA NA 50, * 56, * 115, * NA NA 48, * 80, * 128, * NA NA 29, * 22, * 58, * NA NA 60, * 54, * 125, * NA NA 52, * 41, * 97, * NA NA 17, * 104, * 121, * NA NA 57, * 24, * 81, , * NA NA 33, * 31, * 78, , * NA NA 70, * 98, * 180, * NA NA 22, * 38, * 60, , * NA NA 14, * 55, * 86, * NA NA 79, * 26, * 105, ,2 NA NA 44, * 86, * 89, * 220, ,2 NA NA 31, * 68, * 95, * 194, ,2 NA NA 24, * 35, , * 117, ,2 NA NA 30, * 68, * 113, * 212, ,2 NA NA 9, * 74, * 80, * 164, SOURCE: NATIONAL CENTER FOR HEALTH STATISTICS, NATIONAL HEALTH INTERVIEW SURVEY, , * ESTIMATE FOR WHICH THE NUMERATOR HAS A RELATIVE STANDARD ERROR OF MORE THAN 30 PERCENT. --*NO CASES IN SAMPLE. (1) IN 1997, THE NATIONAL HEALTH INTERVIEW SURVEY COMPLETELY REDESIGNED THEIR QUESTIONNAIRE. THEREFORE, ESTIMATES PRIOR TO 1997 CANNOT BE COMPARED WITH LATER ESTIMATES. (2) THE REVISED QUESTIONNAIRE NOW ASKS RESPONDENTS ABOUT EMPHYSEMA DIAGNOSIS OVER THEIR LIFETIME. THEREFORE, ESTIMATES WILL BE HIGHER.

17 TABLE 9: EMPHYSEMA - SEX-SPECIFIC NUMBER OF CASES AND PREVALENCE RATE PER 1,000 PERSONS, , EMPHYSEMA MALE FEMALE YEAR NUMBER RATE NUMBER RATE ,691, , ,462, , ,484, , ,448, , ,201, , ,264, , ,308, , ,244, , ,275, , ,058, , ,160, , ,061, , ,232, , ,037, , , , ,890, ,326, ,693, ,266, ,637, ,161, ,690, ,434, ,678, ,304, SOURCE: NATIONAL CENTER FOR HEALTH STATISTICS, NATIONAL HEALTH INTERVIEW SURVEY, , (1) IN 1997, THE NATIONAL HEALTH INTERVIEW SURVEY COMPLETELY REDESIGNED THEIR QUESTIONNAIRE. THEREFORE, ESTIMATES PRIOR TO 1997 CANNOT BE COMPARED WITH LATER ESTIMATES. (2) THE REVISED QUESTIONNAIRE NOW ASKS RESPONDENTS ABOUT EMPHYSEMA DIAGNOSIS OVER THEIR LIFETIME. THEREFORE, OVERALL ESTIMATES WILL BE HIGHER.

18 Table 10: COPD-Number of Conditions and Prevalence Rate Per 1,000 Persons By Race and Ethnic Origin, Non-Hispanic Non-Hispanic Non-Hispanic Year Hispanics White Black Others Total CHRONIC BRONCHITIS 1998 Number 533,770 7,472, , ,935 8,977,160 Rate CI of Rate 3 ( ) ( ) ( ) ( ) ( ) 1999 Number 531,322 7,272, , ,877 8,847,646 Rate CI of Rate 3 ( ) ( ) ( ) ( ) ( ) 2000 Number 566,394 7,680, , ,426 9,354,982 Rate CI of Rate 3 ( ) ( ) ( ) ( ) ( ) 2001 Number 679,957 9,066,921 1,193, ,092 11,198,602 Rate CI of Rate 3 ( ) ( ) ( ) ( ) ( ) EMPHYSEMA 1998 Number 121,731 2,597, ,432 46,130 2,959,516 Rate CI of Rate 3 ( ) ( ) ( ) ( ) ( ) 1999 Number 89,451 2,539, ,378 52,932 2,798,963 Rate CI of Rate 3 ( ) ( ) ( ) ( ) ( ) 2000 Number 90,873 2,792, ,025 32,847 3,124,699 Rate CI of Rate 3 ( ) ( ) ( ) ( ) ( ) 2001 Number 130,698 2,632, ,628 55,941 2,983,598 Rate CI of Rate 3 ( ) ( ) ( ) ( ) ( ) Source: National Center for Health Statistics, National Health Interview Survey, Calculations Performed by the American Lung Association's Epidemiology and Statistics Unit Notes: (1) Chronic Bronchitis prevalence was defined as answering "yes" to "Have you been told by a doctor or other health professional that you had chronic bronchitis in the past 12 months?" (2) Emphysema prevalence was defined as answering yes to "Have you EVER been told by a doctor or other health professional that you had emphysema?" (3) 95% Confidence Interval

19 TABLE 11: COPD- NUMBER OF FIRST LISTED HOSPITAL DISCHARGES AND RATE PER 10,000 BY AGE, (1) (4, 5) TOTAL < YEAR NUMBER RATE NUMBER RATE NUMBER RATE NUMBER RATE NUMBER RATE , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , (2) 12, , , , , , , , , , , , , , , , , , , , (3) 9, , , , , , , , , , , , , , , * * 17, , , , , , , , , * * 24, , , , * * 27, , , , * * 28, , , , * * 18, , , , SOURCE: NATIONAL CENTER FOR HEALTH STATISTICS, NATIONAL HOSPITAL DISCHARGE SURVEY, * FIGURE DOES NOT MEET STANDARD OF RELIABILITY OR PRECISION. (1) THIS TABLE REFERS EXCLUSIVELY TO DATA ON CHRONIC BRONCHITIS, EMPHYSEMA AND OTHER LOWER CHRONIC OBSTRUCTIVE PULMONARY DISEASES INCLUDING BRONCHIECTASIS. DATA ON ASTHMA ARE NOT INCLUDED. (2) DATA PRIOR TO 1988 MAY BE DIFFERENT FROM DATA FOLLOWING THAT YEAR DUE TO A REDESIGN OF THE SURVEY. (3) IN 1992, OBSTRUCTIVE CHRONIC BRONCHITIS (ICD CODE ) WAS INTRODUCED. MANY DISCHARGES PREVIOUSLY CODED AS ACUTE BRONCHITIS (ICD CODE 466) WERE ATTRIBUTED TO THIS NEW CODE IN THEREFORE, THE LARGE INCREASE IN THE HOSPITAL DISCHARGE RATE MAY BE DUE TO A CHANGE IN THE ICD CODE FOR CHRONIC BRONCHITIS. (4) THESE ARE SAMPLE ESTIMATES AND MAY DIFFER FROM FIGURES THAT WOULD BE OBTAINED FROM A CENSUS OF THE POPULATION. EACH DATA POINT REPORTED IS SUBJECT TO SAMPLING VARIABILITY. (5) DUE TO ROUNDING, NUMBERS MAY NOT SUM TO THE TOTAL NUMBER OF HOSPITAL DISCHARGES.

20 TABLE 12: COPD - NUMBER OF FIRST-LISTED HOSPITAL DISCHARGES AND RATE PER 10,000 POPULATION BY RACE, (1) WHITE BLACK ALL OTHER RACES (2) NOT REPORTED (3) TOTAL (4) YEAR NUMBER RATE NUMBER RATE NUMBER RATE NUMBER NUMBER RATE , , ,000* , , , , , , , , , , , , , , (5) 321, , ,000* , , , , ,000* , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , SOURCE: NATIONAL CENTER FOR HEALTH STATISTICS: NATIONAL HOSPITAL DISCHARGE SURVEY, ESTIMATES OF LESS THAN 5,000 ARE CONSIDERED UNRELIABLE. * ESTIMATES OF 5,000-10,000 TO BE USED WITH CAUTION. (1) THIS TABLE REFERS EXCLUSIVELY TO DATA ON CHRONIC BRONCHITIS, EMPHYSEMA AND OTHER LOWER CHRONIC OBSTRUCTIVE PULMONARY DISEASES INCLUDING BRONCHIECTASIS. DATA ON ASTHMA ARE NOT INCLUDED. (2) ALL RACES OTHER THAN BLACK AND WHITE. (3) BETWEEN 1988 AND 2000, THE NUMBER OF DISCHARGES NOT REPORTING RACE INCREASED DRAMATICALLY. IT APPEARS THAT HOSPITAL DISCHARGES IN WHITES MIGHT BE DISPROPORTIONATELY UNDERESTIMATED, PARTICULARLY IN LATER YEARS. FOR THIS REASON COMPARISONS BETWEEN RACES SHOULD BE MADE WITH CAUTION. (4) DUE TO ROUNDING, NUMBERS MAY NOT SUM TO THE TOTAL NUMBER OF HOSPITAL DISCHARGES. (5) A NEW CLASSIFICATION, OBSTRUCTIVE CHRONIC BRONCHITIS WITH ACUTE EXACERBATIONS (ICD CODE ) WAS INTRODUCED IN MANY DISCHARGES PREVIOUSLY CODED AS ACUTE BRONCHITIS (ICD CODE 466) WERE ATTRIBUTED TO THIS NEW CODE BEGINNING IN 1992.

21 TABLE 13: COPD - NUMBER OF FIRST-LISTED HOSPITAL DISCHARGES AND RATE PER 10,000 POPULATION, BY SEX, ,2 MALE FEMALE TOTAL YEAR NUMBER RATE NUMBER RATE NUMBER RATE , , , , , , , , , , , , (3) 210, , , , , , , , , , , , (4) 265, , , (4) 272, , , (4) 297, , , (4) 303, , , (4) 300, , , SOURCE: NATIONAL CENTER FOR HEALTH STATISTICS, NATIONAL HOSPITAL DISCHARGE SURVEY, (1) THIS TABLE REFERS EXCLUSIVELY TO DATA ON CHRONIC BRONCHITIS, EMPHYSEMA AND OTHER LOWER CHRONIC OBSTRUCTIVE PULMONARY DISEASES INCLUDING BRONCHIECTASIS. DATA ON ASTHMA ARE NOT INCLUDED. (2) DUE TO ROUNDING, NUMBERS MAY NOT SUM TO THE TOTAL HOSPITAL DISCHARGES. (3) THE LARGE INCREASE IN DISCHARGES SEEN IN 1992 MAY BE DUE TO ADDITION OF OBSTRUCTIVE CHRONIC BRONCHITIS WITH ACUTE EXACERBATIONS (ICD CODE ). MANY DISCHARGES PREVIOUSLY CODED AS ACUTE BRONCHITIS (ICD CODE 466) WERE ATTRIBUTED TO THIS NEW CODE BEGINNING IN (4) NO ESTIMATE AVAILABLE FOR ICD-9 CODE 495