Access to care drives COPD mortality disparities in North Carolina

SAN FRANCISCO — COPD mortality rates varied across North Carolina, often correlating with access to care and other risk factors, according to a pair of posters presented at the American Thoracic Society International Conference.

"What we're looking at is your risk of COPD mortality based on your ZIP code," Alexa M. Zajecka, MD, a first-year pulmonary critical care fellow at East Carolina University Medical Center, told Healio.

The researchers noted that although COPD is a leading cause of mortality and that North Carolina has one of the highest COPD-related death rates in the United States, there has been little research into its spatial clustering at the local level.

Study Findings

Using HHS data from 2018 to 2022, the researchers found 24,784 COPD-related deaths in the state, with an average of 45.4 per 100,000 people. However, the researchers said, these rates significantly varied based on county, with higher rates in rural counties.

Overall, 53% of these deaths were male, 32% had documented tobacco use and most deaths were in adults aged 55 to 75 years.

The researchers also identified 14 primary and secondary spatial clusters for COPD deaths. Five of these clusters had a relative risk value of greater than 2.3, indicating ZIP codes where the risk for mortality was high. The secondary clusters had relative risk values between 1.5 and 1.9, indicating lower risks.

Areas with higher social economic status such as Asheville and the Research Triangle, including Raleigh, Durham and Chapel Hill, had lower risks for COPD mortality compared with rural and other underserved areas.

"A lot of these patients don't have that access," Zajecka said.

Pulmonologist Shortage

The researchers also found correlations between mortality rates in each county and the number of pulmonologists who practiced there, with z scores greater than 1 identifying areas with critical shortages and z scores of less than 1 indicating better access.

Pulmonologist availability varied greatly by county and region as well, the researchers said, with some counties reporting few to no practicing pulmonologists.

Counties with these shortages also tended to have elevated disparity scores and health risk factors, often overlapping with areas known for lower overall health factors such as health behaviors, access to quality health care, socioeconomic factors and physical environment.

Even when residents lived in a county with a pulmonologist available in an adjacent county, Zajecka said, risks for mortality were increased. Zajecka attributed these increases to the demands of continued pulmonary care.

"Let's say you're able to get access to a pulmonologist. They want [pulmonary function tests]. They want you to go to pulmonary rehab. They want you to be able to afford your medications," she said.

Zajecka also noted that travel for care is another barrier for many patients.

"Looking at the pulmonary rehab throughout the state, you have these big deserts that are lacking," she added. "Some Medicare patients who can't drive more than 50 miles for coverage now can't even do pulmonary rehab."

Potential Solutions

Zajecka said that she and her colleagues will use these data to develop better resource management for these areas and that solutions may involve telehealth.

"However, a lot of these patients in these areas don't have internet access. They're still using a flip phone, so that's not going to work. What other options do we have?" she said.

Zajecka said that her team is sending critical care fellows to these rural areas to conduct telehealth between patients and attending physicians.

"We can do it with our fellowship, because that's something that you can do as training," she said. "For us, it's a great experience."

Zajecka and her colleagues are currently looking at using these telehealth visits for other pulmonary diseases such as asthma, ILD, sarcoidosis, pulmonary hypertension and lung cancer, she said, but telehealth alone is "not going to cut it."

Additional options include encouraging fellows to remain in these areas and practice there, as well as recruiting more pulmonologists to these areas via increased J1 visas.

"Right now, over in Little Washington, we have one pulmonologist who's responsible for the entire area," Zajecka said. "Everybody wants to live in Raleigh. That's where we have the highest concentration. But they're oversaturated."

Policy Implications

Zajecka said that the members of the North Carolina chapter of the American Thoracic Society collaborate and that the pulmonologist from Little Washington attended their meeting in April.

"He came to that meeting trying to see what else we can do, trying to work together," she said as they discussed challenges in screening visits for lung cancer, such as paying for van drivers and connecting with patients once results are ready.

"That's the problem that he's running into," Zajecka said. "Convincing somebody that they have to drive 3 hours for further treatment is something I've even run into."

Zajecka said that she and her colleagues plan to use these data to inform policy involving staffing and costs.

"Even if you see a pulmonologist, you don't have access to what is required to help you improve, or if you can't afford that triple therapy, that you're constantly fighting with it," she said. "These are all the questions that we need to broach."

Sources/Disclosures

Source:
Kumar D, et al. Analyzing COPD mortality clusters in North Carolina (2018-2022): A spatial approach. Presented at: American Thoracic Society International Conference; May 16-21, 2025; San Francisco.

Disclosures:
The authors report no relevant financial disclosures.

Topics: COPD, mortality, health disparity