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Fondazione IRCCS Policlinico San Matteo La Salute del Respiro: una attualit nazionale Ernesto Pozzi Clinica Malattie Apparato Respiratorio La Salute del Respiro: una attualit nazionale Ernesto Pozzi Clinica Malattie Apparato Respiratorio Universit di diPavia La Salute del Respiro, epidemiologia, costi sanitari ed implicazioni sociali delle malattie respiratorie croniche ostruttive e delle allergopatie respiratorie Milano, 26 gennaio 2007 Slide 2 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 Slide 3 EPIDEMIOLOGICAL PERSPECTIVES Mortality rates will increase by 50% over the next 15 years Lopez, ERJ 2006 COPD Slide 4 EPIDEMIOLOGICAL PERSPECTIVES CHANGING GLOBAL DEMOGRAPHICS People > 60yr Mortality rates will increase by 50% over the next 15 years Lopez, ERJ 2006 Slide 5 EPIDEMIOLOGICAL PERSPECTIVES MORTALITY IN FEMALES MORTALITY IN FEMALES Mortality rates will increase by 50% over the next 15 years Lopez, ERJ 2006 Slide 6 COPD Mortality by Gender U.S. 1980-2000 Number Deaths x 1000 Source: US Centers for Disease Control and Prevention, 2002 Slide 7 Machado et al AJRCCM 2006 Differences in survival, men vs women, after initiating long-term oxygen terapy Slide 8 EPIDEMIOLOGICAL PERSPECTIVES CONTINUED USE OF TOBACCO Low rates of smoking cessation (~30%) Young smokers (particularly females) Smoking in non-developed countries Mortality rates will increase by 50% over the next 15 years Lopez, ERJ 2006 Slide 9 NET CHANGE IN ACTIVE SMOKING % PER 10 YRS ECRHS I 1990-94; ECRHS II 1998-2002 (9053 subjects, age range 20-44 years at ECRHS I) Janson, Cerveri and ECRHS group ERJ 2006 Slide 10 NET CHANGE IN PASSIVE SMOKING % PER 10 YRS ECRHS I 1990-94; ECRHS II 1998-2002 (9053 subjects, age range 20-44 years at ECRHS I) Janson, Cerveri and ECRHS group ERJ 2006 Slide 11 Global Epidemiology of Smoking Slide 12 EPIDEMIOLOGICAL PERSPECTIVES OTHER RISK FACTORS Occupation Pollution Indoor outdoor Mortality rates will increase by 50% over the next 15 years Lopez, ERJ 2006 Slide 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 Slide 14 Geographical distribution of ECRHS centres Slide 15 PM 2.5 levels across ECRHS centres Slide 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 Slide 17 COPD PREVALENCE >10% tra la popolazione> 40 anni Prevalenza di COPD in aumento costante >10% tra la popolazione > 40 anni Chapman et al. ERJ 2006 3.6% 0-45 years Prevalenza di COPD 3.6% tra la popolazione di eta 20-45 years de Marco et al. Thorax 2004 Slide 18 INCIDENCE OF COPD ACCORDING TO THE HISTORY OF CHRONIC COUGH AND PHLEGM De Marco, Cerveri et al AJRCCM 2006 Slide 19 EPIDEMIOLOGICAL PERSPECTIVES GLOBAL BURDEN Hospitalizations Hospitalizations Number and duration Number and duration Comorbidity Comorbidity Mortality rates will increase by 50% over the next 15 years Lopez, ERJ 2006 Slide 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 Slide 21 EXACERBATIONS AS A STARTING POINT OF PROACTIVE COPD MANAGEMENT Zoia et al, Resp Med 2005 Slide 22 Without diagnosis With diagnosis Patients with and without previous diagnosis EXACERBATIONS AS A STARTING POINT OF PROACTIVE COPD MANAGEMENT Slide 23 Percentage of patients with and without spirometry EXACERBATIONS AS A STARTING POINT OF PROACTIVE COPD MANAGEMENT Slide 24 Slide 25 Slide 26 Diagnosi principalen. dimissionidegenza media Malattia polmonare cronica ostruttiva12018810.01 Bronchite cronica ostruttiva, riacutizzata880839.77 Insufficienza respiratoria7005413.15 Bronchite cronica ostruttiva, non riacutizzata2297812.00 Bronchite, non specificata se acuta o cronica42164.69 Bronchite cronica semplice232810.04 Bronchite cronica non specificata20399.36 Bronchite cronica mucopurulenta125610.33 Epidemiologia della BPCO Ricoveri in regime ordinario SDO - Ministero della Salute, 2005 Slide 27 Hospital stay 60 days180 days1 year2 years Mortality (%) 60 50 40 30 20 10 0 COPD Exacerbations : Mortality 11% 20% 33% 43% 49% Connors AF Jr et al. Am J Respir Crit Care Med. 1996;154:959-67 1016 pts with severe COPD exacerbation (PaCO 2 > 50 mm Hg) Slide 28 Total costs ( billion) of respiratory diseases in Europe in 2000 Slide 29 Piano sanitario nazionale 2006-2008 Slide 30 ASTHMA PREVALENCE IN ADULTS:GOOD NEWS? ASTHMA PREVALENCE IN ADULTS:GOOD NEWS? Weiland and Pearce Editorial Thorax 2004 THE EPIDEMIC HAS ENDED,OR HAS IT ? THE EPIDEMIC HAS ENDED,OR HAS IT ? Shafazand and Colice Editorial Chest 2004 THE PREVALENCE OF ASTHMA IS NO LONGER INCREASING IN SOME COUNTRIES THE PREVALENCE OF ASTHMA IS NO LONGER INCREASING IN SOME COUNTRIES Anderson Editorial BMJ 2005 Trend dellasma negli adulti non in ulteriore aumento in parecchie nazioni Slide 31 INCREASE IN DIAGNOSED ASTHMA BUT NOT IN SYMPTOMS IN THE EUROPEAN COMMUNITY RESPIRATORY HEALTH SURVEY Chinn,Jarvis, Burney,Cerveri et al Thorax 2004 Slide 32 NET CHANGE IN IN PREVALENCE ( per 10 years of follow-up) OF SYMPTOMS, DIAGNOSED ASTHMA, AND CURRENT MEDICATION IN THE ECRHS Chinn, Cerveri and ECRHS group Thorax 2004 Net change (%) Wheeze without a cold Woken with chest tightness Woken with shortness of breath Current medication Diagnosed asthma Attack of asthma * * * * p = 0.011 ** p 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 no use of hospital services Heavy burden > 12 lost working days or > 3 days per months limited or use of hospital services THE BURDEN OF ASTHMA REMAINS SUBSTANTIAL IN EUROPE A DECADE AFTER THE GINA GUIDELINES (ECRHS II; 1999-2002) Accordini, Cerveri and ECRHS group Allergy 2007 Slide 44 THE BURDEN OF ASTHMA REMAINS SUBSTANTIAL IN EUROPE A DECADE AFTER THE GINA GUIDELINES (ECRHS II; 1999-2002) Accordini, Cerveri and ECRHS group Allergy 2007 Light burdenLight burden up to 12 lost working days or up to 3 days per months limited no use of hospital services Heavy burdenHeavy burden > 12 lost working days or > 3 days per months limited or use of hospital services FEV1 % predicted Slide 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) 45% Controlled asthma 55% Uncontrolled asthma Peters et al JACI 2007 Slide 46 PREVALENCE OF ASTHMA TREATMENT ADHERENCE AT ECRHS I AND II ECRHS I 1992-3 ECRHS II 1998-2002 Corsico,Cerveri and ECRHS group Resp Med 2007 Slide 47 Utilizzo farmaci R03 (antiasmatici) Bisogno terapeutico teorico ITALIA CAMPANIAEMILIALOMBARDIA DDD = dose media mantenimento giornaliera Dati Fondazione SKF Slide 48