Meilan King Han, MD, a professor of internal medicine at the University of Michigan, discusses how her practice has altered patient care to adapt to the ongoing pandemic and challenges patients with chronic obstructive pulmonary disease (COPD) and providers face when dealing with a highly contagious airborne respiratory virus. 

As coronavirus disease 2019 (COVD-19) deaths and cases continue to climb in the United States, patients with conditions that can exacerbate COVID-19 severity, such as chronic obstructive pulmonary disease (COPD), have had to adjust to transitions in care delivery and maintenance.

Although the prevalence of comorbid COPD among those 

 is lower than that of the general population, patients with COPD are 3 times more likely to die from a COVID-19 infection.

 utilization has become paramount to ensuring individuals receive quality and timely care while adhering to pandemic guidelines.

However, as Meilan King Han, MD, a professor of internal medicine in the Division of Pulmonary and Critical Care at the University of Michigan explained, because patients with COPD knew they were at increased risk of COVID-19 complications, many experienced fewer exacerbations over the course of the pandemic due to less exposure from external triggers.

The American Journal of Managed Care®(AJMC®) 

Han laid out how her practice has altered patient care to adapt to the ongoing pandemic and elaborated on challenges patients with COPD and their providers face when dealing with a highly contagious airborne respiratory virus.

Han is a physician and researcher with a focus on chronic lung disease and COPD. She is also a national volunteer spokesperson for the American Lung Association.

The following interview has been edited for length and clarity.

 The CDC classified individuals with COPD as being at a higher risk of experiencing more severe COVID-19 symptoms. Nearly a year into this pandemic, what do we know about how these 2 conditions interact?

I think it's really interesting because one thing that has happened is that many patients with COPD got the message that they were at increased risk and have been doing, I would say overall, a fairly good job of staying at home. What I would say, on the ground, at least in my own practice, as well as with talking to other physicians around the country, is that one odd thing that we're seeing is that patients with COPD in general are having fewer exacerbations of their disease than we would normally see. We know that in normal times, exacerbations would be due to things like normal colds, and other non-COVID-19 viruses. The interesting thing is that overall, we're seeing patients having fewer exacerbations simply because they're heeding the CDC guidance and staying at home.

Now, this does not mean that no one is getting sick. I have more recently seen several of my patients with both things like COPD as well as asthma become sick with COVID-19. The studies really do indicate that patients who are either older—which COPD patients tend to be, we know that the prevalence increases with age—as well as have underlying conditions such as COPD, truly are at increased risk for poorer outcomes. Certainly, I've had some of my own clinic patients, unfortunately, do poorly when they've contracted COVID-19. For every patient, there's still a wide range of disease severity, even within the group of patients who have COPD. But we know that as a group, they are at increased risk for more severe COVID-19.

What extra pressures or challenges do patients with COPD face during a pandemic that is wrought by a respiratory virus?

We're seeing tons of challenges. One of them is just attaining regular medical care. Many patients with COPD live in rural areas, and they also tend to be, as a group, more socioeconomically disadvantaged. They're also afraid. What this means is that in a pandemic they're less willing to travel. They may not be able, for instance, to get someone to drive them because of the risk of that, and so they're having a harder time making it to in-person appointments when that's an option. They're also having a harder time doing virtual visits, because I'm finding a lot of them don't have the appropriate technical equipment that would require. We still are allowed to do phone visits, but it's unclear how long that those will continue to be reimbursed for.

I will also say, I've had one patient in particular that I did a video visit with who then was admitted to the hospital not long afterwards. And I wondered whether if I'd actually seen her, I would have realized perhaps how sick she was. But it's just difficult, even with video, to not be in the same room with a patient and observe how they're breathing and to listen to them and talk to them and watch them walk around. It's just not the same overall experience.

The other thing I'm finding a challenge is even how to do things like patient education. Normally, my nurses would go into the patients' rooms and would review inhaler techniques with them. We've never really tested this system out virtually. Like I said, many of my patients don't even have video as an option, so that's getting harder and harder.

The other problem that we've noticed is that many of the pulmonary rehabilitation centers closed during the pandemic. Many of them are back open, and are taking significant precautions, but these are intended to be shared spaces. Rehab is often performed in groups. So, getting patients in pulmonary rehabilitation has been hard.

Other things that have been challenging include things like some of the treatments that many of our patients receive. Things like nebulizers, which are aerosol generating procedures, can be challenging, because if a patient has COVID-19, they could be aerosolizing COVID-19 particles to anyone that they might be sharing a home with, for instance. We had developed specific guidance for patients if they already become infected about trying to isolate when using nebulizers. The same thing goes for continuous positive airway pressure (CPAP) machines. Those also can generate aerosols and spread virus. So, if you have an actively infected patient they need to be sleeping alone, for instance, when using the CPAP machine. I think almost every aspect of life for COPD patients has been affected by the pandemic.

 In your practice how has the pandemic altered care? Are you doing predominantly telehealth visits or phone visits with patients?

I've been doing a mix depending on how bad the surge is. In Michigan, where I live, the surge was really bad in the spring, and at that point, the hospital encouraged us to move to almost all virtual visits. Things were much better in Michigan over the summer. I was able to get many of my patients back in for in-person visits and check their spirometry and tried to get issues sorted out in person.

We're now in the middle of a second surge. I have re-transitioned many of my visits back to virtual and we're kind of doing a mix. One thing that's been really challenging is just even doing pulmonary function testing on patients because this is also an aerosol generating procedure. Health systems have taken 1 of 2 approaches. Either they will test for COVID-19 first, or they will not test but the technicians and therapists that are doing pulmonary function testing have to wear full personal protective equipment (PPE) and will try to even do those in a negative pressure room if it's available. Even bringing people in when things were better was still more cumbersome than it typically would be.

Right now, I'm doing a mixture both in-person and virtual. The question on all my patients' minds right now is "When can I get the vaccine?" As we know the government and CDC have recommended currently individuals over 65 and individuals with conditions that would put them at increased risk [of COVID-19 complications should be vaccinated]. I think the majority of COPD patients would fall into that group that really should be prioritized for vaccination.

In Michigan and at Michigan Medicine, they started rolling that [protocol] out and scheduling this week, but then put a halt on it because we did not get a shipment of vaccine that we were expecting. I'm kind of just sitting here waiting to see what's going to happen with that. I know that at a national level, we've been told there's plenty of vaccines, but Michigan did not get an expected shipment this week. I really have yet to see any of my COPD patients receive the vaccine yet.

Are most of your patients eager to get the vaccine or are you confronting any hesitancy?

 I would say the majority of patients are eager to get the vaccine and are trying to sign up in as many places as they can think of; if they've seen physicians at 2 health systems, they're signing up with both health systems. They're signing up with multiple pharmacies. I have received some patients that have concerns. Patients, for instance, that might be on immunosuppressive medications, or have had other specific questions. Some younger patients, not my COPD patients, have had concerns or they may have seen in the media, for instance, things about pregnancy. But I would say for the most part, my COPD patients have been quite eager to be vaccinated.

 How do you think the pandemic will affect treatment paradigms moving forward? Do you think there will be any long-term impacts?

I do, and I'm hoping that they're for the better. I know that getting into the health system for care has always been a challenge for COPD patients, even outside the pandemic. I'm hoping that we can make at least some version of virtual [care] work for patients and figure out how to do that.

But in order to do so we've got to solve some of the technology problems. We need to figure out how to better deliver patient education virtually. We also need to figure out how better to deliver pulmonary rehabilitation, I think in a virtual format. Certainly, there are pulmonary rehab programs that are virtual that exist but trying to figure out how to help patients access that has been a challenge. Another thing that we've seen is, there are portable spirometers that are available. There are companies that manufacture these. They exist and the platforms exist to get these into the hands of patients, but how to bill for them, how to monitor, how to use that information, how to get that information into the electronic medical record, such as EPIC that we're on at the University of Michigan, and I think many health systems are on, those details have not yet been sorted out.

I think this is an opportunity to try to figure out all of these issues, such that we can better deliver care in a way that patients most need it in the future. Interestingly, before the pandemic The University of Michigan had as a goal to transition roughly 30% to 35% of all patient visits to virtual…just to increase access. I would envision that, in the future, I will have better ability to provide care virtually for patients, including patient education and rehab and mobile spirometry, if that makes sense for the patient.

But I don't think this means in-person visits will go away. I think in the future, we will probably be looking at a hybrid approach where patients might do virtual visits, for instance, alternating with in-person visits or perhaps, doing urgent add-on visits virtually if that's the most convenient for both the patient and the provider. My hope is that this will sort of improve options to optimize patient care moving forward because we've been forced to figure out how to deliver care in different ways during the pandemic.

Is there anything that we haven't covered that you would like to discuss, or do you have any final thoughts you'd like to share?

The best final wrap-up thought would be just encouraging patients who do have COPD to get vaccinated as soon as they are able. I have no reason at this point to believe that the vaccines are not safe or effective in the patient population that we're discussing. And I am strongly recommending that all of my COPD patients get the vaccine as soon as they can.

COPD & COVID-19: An Interview With Dr MeiLan Han

Anzueto, a professor of medicine at the University of Texas Health in San Antonio and clinician practicing pulmonary and clinical care, also serves as a member of the GOLD Science Committee.


Each year the Global Initiative for Chronic Obstructive Lung Disease (GOLD) releases a report on updated guidelines for chronic obstructive pulmonary disease (COPD) treatment and disease management. In the 

, changes mainly reflected treatment recommendations for patients with COPD who develop coronavirus disease 2019 (COVID-19), explained Antonio Anzueto, MD, in an interview with 

In addition to recommendations on COVID-19, the updated report highlights new research on COPD therapies, diagnosis, and rehabilitation programs. In this interview, Anzueto discusses the benefits of triple therapy for COPD, adherence issues patients may face, and the importance of correctly diagnosing the disease.

Anzueto, a professor of medicine at the University of Texas Health in San Antonio and clinician practicing pulmonary and clinical care, also serves as a member of the GOLD Science Committee.

What are some of the key updates made to the GOLD 2021 report, and why are they important?

 Probably the main update in the report is having a section related to how COPD patients should be managed in the COVID-19 area. In this document, we emphasize the need to continue their current appropriate medication, to do the evaluations and diagnostic procedures. We recognize there are limitations in the use of spirometry due to COVID-19 and the risk for contamination. But that doesn't mean patients should not continue their appropriate therapies, as well as the prevention measurements, such as smoking cessation and pulmonary rehab. We specifically also recognize that COVID-19 may not finish the day the patient starts feeling better, that patients may have some long-term effects as part of COVID-19. We have a section on follow-up assessment for COPD patients after they develop COVID-19. The main areas are related to the management of COPD patients during the COVID-19 pandemic.

What are the goals for this year's GOLD report?

 I think one of the main goals is going to be to fully understand how the pandemic is impacting our COPD patients. More importantly, how the vaccine will be able to protect these patients. We're looking forward as the vaccination is being implemented in older individuals, individuals with comorbid conditions, to understand the efficacy as well as the safety of the vaccine to protect our patients with COPD or with chronic lung disease.

What are some of the benefits of triple therapy in patients with COPD, and can you discuss any potential risks of pneumonia?

 I think it's important to recognize that COPD today is a treatable condition. It's crucial to make a diagnosis to know what the disease is. And once we recognize the diagnosis, the important thing is to implement pharmacotherapy for these patients. Since the 2000s, beginning in 2010 to 2015, the standard of care has become the use of inhaled corticosteroids [ICS]/long-acting β2-agonist [LABA] in a fixed combination and the long-acting anticholinergics. Since triple therapy has become available in a single inhaler—first as a once-a-day with a combination of fluticasone, vilanterol, and formoterol, and later on with a twice-a-day formulation of budesonide, formoterol, and glycopyrrolate—we clearly have better opportunities for the management of our patients with COPD.

We have recognized also, for the last 15 years, that patients who receive inhaled corticosteroids are at an increased risk to develop pneumonia. Further studies in that area clearly recognized that the individuals who are sicker, and individuals who have very low eosinophil counts, are the ones at an increased risk of developing pneumonia. The clinical trials in patients on the triple therapy, the ICS/LABA/LAMA [

-acting muscarinic antagonist], versus the dual therapy LABA/LAMA without inhaled corticosteroids, demonstrated that there is an increased risk of pneumonia.

What I tell my patients is, yes, the potential risks have increased for pneumonia, but I'm doing everything that I can to prevent pneumonia. I try to be sure patients get up-to-date on influenza vaccinations. I try to keep them up-to-date on pneumococcal vaccinations both for the conjugated vaccine as well as the polysaccharide vaccine and [make sure] they are given at the appropriate time. Today we also understand that the diphtheria, pertussis, and tetanus [DPT] vaccine should be included in the management of patients with chronic lung diseases.

In a lot of the data on the risk of pneumonia and inhaled corticosteroids, the piece of data that is missing is the history of vaccination, especially pneumococcal vaccination. Clinical studies have demonstrated that pneumococcal vaccinations can give a significant protection especially to the serotypes included in the vaccine. I tell my patients, yes, you are at risk to develop pneumonia, but I'm trying to do everything that I can...This is a matter of risk/benefit. I believe that the benefit [of triple therapy] outweighs the risk primarily with the protection in reduction in exacerbations, improvement in quality of life, as well as improvement in lung function.

Studies on triple therapy have indicated it can result in a reduction in all-cause mortality when compared with dual and monotherapies. Is this finding a class effect?

 I think it's hard to say if there is a class effect, if this is an effect of inhaled corticosteroids alone or this is an effect of the combination of medications. If we go back to 2000, there was a study called 

, and there were patients who were on ICS/LABA and they had the long-acting anticholinergic tiotropium added to the regimen. That study was versus placebo. There was a group of patients who were on ICS/LABA and placebo and patients who were on ICS and LAMA tiotropium. There was a significant reduction in mortality in the triple therapy group. I think, at the end of the day, there may be some effect with inhaled corticosteroids in the decreased mortality. But the benefit is being obtained and having the triple therapy, having the dual bronchodilators given together with inhaled corticosteroids, that would give the largest protection to the patients.

What are the main adherence challenges to triple therapy that your patients face?

 For COPD, we have great medications available. As a matter of fact, 28 different medications have been developed over the last 15 to 20 years. And we can have the best medication in the world, but the patient cannot get it. That's a tremendous challenge. We are beginning to recognize that there are factors related to the individual, like their ability to generate enough inspiratory force to have a medication penetrate into the lungs, that is a very significant element, as well as coordination with the delivery systems, that [impact whether] they are able to get their medication. The GOLD committee has recognized, since 3 years ago we proposed in the algorithm of management that when the patient comes back to us for follow-up, and the patient tells us "I don't feel fine, I'm not doing well," before we jump into changing medication, adding or removing medications, we should address their ability to take the medication and their techniques. Having medications from different delivery systems—some dry powder, some are hydrofluoroalkane [HFA] formulation, some are soft mist, some are nebulized—these give us a very unique opportunity to tailor that delivery system to the patient's actual needs.

Can you elaborate on the role of critical errors in inhaler use and how these may impact patient outcomes?

 When using the delivery systems and using the medication, certainly, there is a series of steps that the patient has to take in order to have the medication get into the lungs. Some of the challenges that we have are patients have to follow all those critical steps, because if they exhale too fast or inhale too slow, they don't follow those steps, they are at an increased risk of not getting the medication they need into the lungs.

One of the big challenges that we have today is trying to match the medication delivery to give them the appropriate medications…Some patients cannot do it in the powder form, it may be easy for them to do in an HFA form and vice versa. But it's very important, every time we assess our patients in our follow-up, to have them show us how they use the delivery system and remind them the appropriate way to use the delivery system.

, in 2011, about 5.4% of Texas residents surveyed had been told by a health care professional that they have COPD. In your experience, have you seen any trends in diagnoses in the state with the rising popularity of vaping or any external environmental hazards?

 We have seen [trends] primarily from policies more related to cigarette smoking. We have seen a significant increase of patients diagnosed with COPD, because we are doing more spirometry [testing]. We're looking more at the management of their condition. So yes, we do see an increase in diagnosis of these patients.

Is there anything we didn't touch on that you'd like to include, or do you have any final thoughts you'd like to share?

 It's very important to remind you that COPD is a treatable disease, but in order to treat it, we need to know what the patient has. One of the major concerns that I have is that many people have been labeled to have COPD never having [completed] spirometry, and if you do a spirometry test, they don't have COPD. So, the feeling that people happen to smoke, that doesn't mean they can develop or they're going to have COPD. Today, the gold standard is with the spirometry test… The important issue is we have to make a diagnosis of the disease because this is a treatable disease. If you make the right diagnosis, we have a tremendous opportunity to impact this patient's quality of life and lung function. Now we have seen with the recent publications of the triple therapy, you're not only reducing exacerbations, as well as improving quality of life and lung function, you may be reducing mortality, so we may impact the disease in ways we never suspected before.

Dr Antonio Anzueto On the Benefits of Triple Therapy, Importance of Accurate COPD Diagnoses  

Gerard Criner, MD, FACP, FACCP, offers insights on the next steps for triple therapy, challenges of early COPD diagnosis, and how the pandemic could impact long-term lung health. 

Although chronic obstructive pulmonary disease (COPD), is among the leading 

 in the United States, many challenges remain when it comes to diagnosis, treatment, and management. Now, with coronavirus disease 2019 (COVID-19) threatening to damage even healthy lungs that become 

, pulmonologists are concerned the disease could lead to an uptick in COPD diagnoses or other lung related-issues in the long term, said Gerard Criner, MD, FACP, FACCP, an interview with 

Criner is a professor and chair of the Department of Thoracic Medicine and Surgery at the Lewis Katz School of Medicine at Temple University. As an active clinical investigator in advanced lung diseases, primary COPD, pulmonary fibrosis, and respiratory failure, Criner offered his thoughts on the next steps for triple therapy, challenges in diagnosing early COPD, and lessons learned from the COVID-19 pandemic. 

Triple therapy can be associated with increased risks of pneumonia. An analysis of 

 showed an increased incidence of pneumonia in patients in Asia compared with those outside of Asia. An additional 

 comparing Western Europe and North American regions found an inhaled corticosteroids (ICS) class effect of increased pneumonia incidence in North America but not in Western Europe. What factors contribute to these findings?

 That finding isn't a first finding. That's been demonstrated before in Asian populations. They have a higher increase of pneumonia with ICS use compared to trials that have been done outside of Asia, such as in the United States or in Western Europe. There's a number of factors [contributing to] that.

It might be something to do with the environment, with the prevalence of other types of infections such as tuberculosis that may cause bronchiectasis, or more structural airway abnormalities that lends to colonization with organisms that may predispose to pneumonia. Some might be due to host factors. Childhood illnesses may be different in one part of the world than the other one.

There also could be environmental causes that could contribute to it. It may just be as simple as that some patients in Asia are leaner than patients in non-Asian populations. It could be the relative dose of steroids that the patient receives could be greater because their body mass is lower. It could be just that the clinical care is different, that the use of x-rays in the diagnosis of pneumonia might be more frequent in Asian populations because the clinical paradigm there might be to consider pneumonia based on clinical parameters or the use of radiographs [compared with] other cultures. The exact reasons aren't known.

The IMPACT and ETHOS trials found beneficial effects of triple therapy vs dual therapy on mortality. But this was only in symptomatic COPD patients who had a history of frequent and/or severe exacerbations and who were previously receiving maintenance therapy with triple therapy, long-acting beta2-agonists/ICS, or single or dual long-acting bronchodilators. The 

 stated, "Future analyses or studies may help determine whether other specific patient subgroups demonstrate a greater survival benefit." In your opinion, which patient subgroups ought to be studied next? What are the next steps for research into triple therapy?

 The 2 studies that you just mentioned that showed that there was a survival advantage, those were prespecified analyses, but they weren't the primary outcomes of the studies. The FDA and other regulatory bodies have not approved the use of triple therapy to improve survival in patients who were in those studies. I think that's the first place to start: an approved indication for the use of inhaled triple therapy for patients with COPD. We would like to see that as approved therapy. I think that it's not a stretch now that the 2 studies that you mentioned and the pooled analysis from the 

 and TRELEGY studies also showed an improved survival in a pooled analysis of those studies.

We believe that it's true, it's a class effect; that in the appropriate patients, triple therapy improves survival. Those studies, as you mentioned, [were conducted on patients who] were highly symptomatic, people with frequent or severe exacerbations. The other patient groups that would benefit from this are people who aren't as symptomatic, who are still with severe exacerbations.

Should triple therapy be something that every patient who's hospitalized receive on exit from the hospital and remain on therapy for a period of time? Those are the patient groups I think we need to study, people that have severe exacerbations, [who] are hospitalized but may not be as symptomatic. How long should they be placed on triple therapy? I think we also need to solidify the patient groups that were studied in ETHOS and IMPACT to get an approved indication for triple therapy.

Can you elaborate on some of the limitations of using the forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC) ratio to diagnose COPD?

 COPD is more than just an airways disease. There's a lot of symptomatology, morbidity, and mortality that's outside of what can be measured from the FEV1, such as comorbid clinical conditions and important changes COPD [has] on musculoskeletal strength activity. That's one limitation: that any spirometric measure, just not the FEV1/ FVC, is important in characterizing the burden of disease that patients with COPD have. Besides that, the FEV1/FVC just measures the degree of airflow obstruction. We know that some patients can have significant smoke-related or other host factor–related (such as environmental pollutants, etc) changes in lung function and can develop emphysema that may not be reflected by airflow obstruction. That definitely is a trait that patients have that importantly contributes to their outcome.

There are also patients where an absolute cut point of FEV1 to FVC does not identify the burden of their disease or their likelihood of developing COPD later. There are people who surround the border, the threshold variable for FEV1/FVC, which is currently 70%. Patients can still have significant symptoms in outcome; that's been shown in several studies now, where patients can have preserved spirometry and still be symptomatic with COPD-like symptoms and respond to treatment and have a differential outcome. There are several limitations to just using a threshold variable of obstruction identified by the FEV1/FVC ratio.

What are some of the challenges involved in early COPD diagnoses or designating individuals as having pre-COPD?

 There's ups and downs about trying to do that. One of the things that we would like to do is identify patients who have an earlier phase of COPD or a predilection to develop COPD, patients who are at risk, and be able to intercede before they get fixed airflow obstruction. The problem is that not everyone who has symptoms of mucus hypersecretion, or cough, or shortness of breath go on to develop COPD. You don't want to label patients with a disease when they don't have a disease or even a path to develop the disease. Because the stigma and the consequences and the likelihood of overtreatment for that patient group could be worse than having the label of the disease to begin with.

I think, overall, we need better ways to detect patients who are predisposed to develop COPD, that currently we don't have. Patients' symptoms aren't robust enough to do that. Radiographic imaging carries another risk for people who use it at a younger age. That may increase the cost of care, but also, needless exposure to radiation isn't something that we want to do. We don't have a specific and straightforward biomarker that can indicate patients who are at risk for COPD, like we have for patients who may be labeled prediabetic based on a biomarker such as glycosylated hemoglobin.

There's clearly more work that needs to be done to enhance our ability to capture patients who are at risk for developing COPD, before they have intractable airflow obstruction that exists. Currently, we don't have that, but we need to work hard to try to discover that.

Reports of COPD exacerbations have decreased since the pandemic due, in part, to reduction in external exposures. Is there anything that pulmonologists can learn from the lockdown and implement going forward when it comes to improving disease management?

 We've seen that both in clinical trials and also in clinical practice that patients developing acute exacerbations of airflow obstruction, whether they have COPD or asthma, are both less. At our institution so far this year, we've only seen 2 documented cases of influenza, which is markedly different from what we see in any other year. Prevention of aerosol contact with one individual for another one is something that has been the only good benefit that I can see of COVID-19, with social isolation, wearing masks, and better hand hygiene. I think we can learn a lot from that, that [during] peak seasons of the year where populations are at risk, perhaps using those preventative measures would be something that could be very important to lessen the morbidity and mortality associated with viral and bacterial infections that occur throughout the winter months when people are in closer quarters.

It's been proven now that COVID-19 can result in both short- and long-term lung damage. Do you anticipate any long-term impacts of COVID-19 on otherwise healthy lungs that could potentially lead to an uptick in COPD diagnoses or other lung-related issues?

 Yes, unfortunately, I think we will see that, and we have been seeing that. The true magnitude of that problem isn't really clear right now. We thought that, based on the prior experiences with severe acute respiratory syndrome [SARS] 1, that incidence might be 1% to 2% at most, that the likelihood of persistent problems would not be greater than SARS 1. But it appears that it probably is slightly greater. How greater, it isn't known.

For the most part, obstructive airways disease doesn't seem to be as prevalent as parenchymal inflammatory disease with fibrotic changes or with persistent ground glass opacities, which appear to be much more apparent. But I think we'll know a lot more in the next 6 to 12 months [regarding] how many patients have this problem, what the nature of that problem is, and is it only patients with severe COVID-19 infection, hospitalized, or [in] an intensive care unit? Or even in people with milder forms of infection who never were hospitalized? What is the nature of their problem in the long term?

Dr Gerard Criner Offers Insights on Early COPD Diagnosis, Next Steps for Triple Therapy

Trisha Parekh, DO, discusses her research on the impact of psychological stress on low-income patients with chronic obstructive pulmonary disease (COPD). 

The COVID-19 pandemic has brought social determinants of health into sharp focus in the United States. But for many Americans these factors, which can include food instability, housing, unemployment, and transportation, have hindered access to quality health care for years.

Among individuals with chronic diseases, barriers resulting from social determinants of health can be all the more burdensome. In an interview with

), Trisha Parekh, DO, discussed her research on the impact social determinants of health, in particular psychological stress, has on low-income patients with chronic obstructive pulmonary disease (COPD).

Parekh is an assistant professor of medicine in the pulmonary, allergy, and critical care medicine division at the University of Alabama at Birmingham.

What are some of the social determinants of health commonly associated with poor outcomes among patients with COPD?

 Specifically with COPD, the most information that we have is in the low-income population. We know that low-income patients who have COPD have higher rates of readmission, higher hospitalizations. They have lower lung function. They also have higher rates of mortality. There's a definite clear association between income and poor outcomes in COPD. Of course, there are so many other social determinants of health.

What drew me to this area of research is realizing that there are all these other factors that really impact our health, but really aren't getting that much attention…One of the problems with our current health care system is that the majority of times, due to time constraints and the need to see a certain number of patients in a day, a lot of us will see a patient, will talk to them about harmful effects of smoking, which they know. You advise them to quit, you give them a prescription for inhalers, and you set them up with pulmonary rehab, and you send them on their way. But without asking anything further, you're not going to know that they don't have transportation to take them to pulmonary rehab…You won't know that they can't afford their inhalers, so they won't be using them. You won't know that they're struggling with social situations at home that are so stressful that smoking becomes the only constant in their life, the only comfort in their life. In those situations, how can we expect someone to be a model patient? Those circumstances are so difficult to deal with…There's a huge interplay between everything else that goes on in our life and our health. It's important for us as physicians and health care providers to look at the patient beyond that 30-minute appointment slot that we have with them to really see what else is going on in their life that could be impacting their health.

 you conducted in March 2020 found high-stress groups with COPD had a 2.5-fold increased adjusted odds of acute care use compared with the low-stress group. In the low-income and high-stress group, that was even higher at a 4-fold increase adjusted odds of acute care use. These patients with high stress were also more likely to be female and under the age of 65. Can you elaborate on the significance of these findings?

 We were interested in one, just looking at social disadvantages in our COPD population. Because I think a big problem with trying to evaluate social determinants of health, address social determinants of health, or determine their impact on COPD outcomes, is the fact that we don't really have that much data. We don't have a lot of large databases that include information about someone's food access, or someone's stress level. That was really a main goal of this project, to develop this cohort.

We did that through a survey study that assessed various social determinants of health as well as COPD outcomes in these patients. What we were interested in looking at initially was, “What does stress do for COPD patients?” We did find in an adjusted model that people who had higher levels of stress more than doubled the odds of utilizing acute care services, either going to the emergency department or getting hospitalized for a COPD exacerbation…We wanted to look at, “Does having low income and high stress interact differently with COPD outcomes, compared to those who are in different situations?” What we did find is that, compared to people who have low stress and high income, those who had high stress and low income had a 4-fold increased risk of utilizing acute care services. The study is limited by its cross-sectional design. It is a relatively small sample size, and it was just at a single center. But there are clear associations that we're seeing between stress and poor outcomes in COPD.

community health worker–led stress reduction intervention

 for low-income patients with COPD. Why did you decide to pursue this model? Can you give an overview of this program and lay out some of your goals?

 This is an NIH-funded study that is an early career development award, which I'm really excited about. It just started last year. The overall goal of this project is to really understand root causes and clinical implications of stress in a low-income COPD cohort, so as to inform the development of a stress reduction intervention for the COPD patients. That stress reduction intervention is going to be based on a community health worker approach.

Community health workers are trusted, lay health workers. They are the leaders in the community, the trusted advisors, the people that you would turn to for advice. They're kind of a natural born leader in their community. And what we have seen is that through these community health worker interventions—where you take this group of community health workers and you train them in a specific area, whether it's in diabetes education, or stress reduction, or interventions focused on improving depression—these interventions have been very successful, especially in chronic diseases. They've been shown to reduce hospitalizations, lower blood pressure, improve weight loss, increase cancer screening rates, and reduce stress levels.

One of the major pitfalls that we've had thus far in trying to reduce hospitalizations in COPD—which is really what everybody wants, to improve these hospitalizations and readmissions—is that these interventions are not designed with community input, but they're for the community. That, to me, was always baffling, that we are implementing these interventions in the group of people without getting their advice on what would work for them, and how it would best work. I think community health workers are the perfect connection between the health care provider and the patient. There's just an automatic level of trust there that is difficult to build between a physician and a patient who are meeting for the first time.

It's a 5-year project with 3 different parts to it. The initial 2 parts are going to be evaluating sources of stress and really understanding stress in the COPD population. The first aim of the study will be administering surveys to a number of participants in the multicenter SubPopulations and InteRmediate Outcome Measures In COPD (

) study. We'll be administering surveys to participants in this study that would assess various social determinants of health and also assess their stress levels. With that, what we'll be able to do is address one of the limitations of that earlier paper by looking to see if stress levels predict exacerbations prospectively. In the year that follows, if I have high stress levels today, is that associated with increased risk of exacerbations in the next month, or 3 months, or 12 months?

The second part of the study is really going to be understanding these stressful experiences that COPD patients go through. I think this is probably one of my favorite parts of the study because it involves in depth interviews and one on one sittings with a participant to really understand what happens in day-to-day life that's stressful and how [the patient] responds to this stress…We know that chronic stress can impact your pituitary adrenal axis, it can stimulate your sympathetic nervous system, so you end up with these chronically elevated cortisol and inflammatory levels. Over time, that can suppress your immune system leaving you susceptible to infections, which is of course the thing we're trying to avoid. I think this partially explains why we see the higher exacerbation rate in low-income communities. I'm hoping that we really get a more in depth understanding of what's going on as soon as our patients leave the clinic floor.

The final aim of this study is to combine what we learned in those first 2 parts. We're getting a lot of data from that first aim, then we're getting a lot of deeper understanding from that second aim. I want to combine [those 2 components] and develop an intervention that would have stakeholder involvement. We would include community health workers to get their input. We would include participants who have COPD to get their input as well. [The intervention] would work to reduce stress, reduce the negative effects of stress like tobacco use, hopefully improve quality of life and hopefully, down the line, improve acute care use. I think overall, if this intervention could be successful, it could be implemented in a number of sites. It's something that we would want to test outside The University of Alabama at Birmingham as well. Hopefully, it's something that can be replicated in other institutions, so that it can be a strong and solid model that incorporates not just the medical aspects of an individual’s health care, but the social aspects as well.

It sounds like based on that model, you’re prioritizing local-level interventions, because individuals on the ground have more experience with the certain specific factors contributing to patients' stress. Is there anything that can be done at the systemic level that would ease these social determinants of health?

 The goal of this is that if we can develop a community health worker intervention that is successful, then eventually it is something that will be supported on a larger scale and something that could be implemented in large institutions. It's something that could be funded by the government.

I think the problem now is a lot of these issues are best addressed at a societal level. But to start, I think that more of these smaller studies are needed to provide that data for larger institutions, or for policy makers, or for different value-based payment models, that could be interested in these innovative solutions.

One aspect is, if we can broaden the implementation of these interventions and if we can get payment for some of these interventions [it may help this process]. Also, going back to data, I think if we can get to a point where on a systems level we are obtaining social determinants of health data, that would probably be the first place to start. Because it's difficult to know what the needs of your community are. Without understanding those needs, it's difficult to address those needs and allocate resources appropriately. When it comes to even thinking about these issues on a larger level, I think policy makers and larger societies are somewhat overwhelmed, because you don't know where to allocate your resources. You don't know who needs what, and I think it's because of that lack of data. The good thing is that there is a larger push to assess social determinants of health. Now the National Academy of Medicine, the American College of Physicians, National Academies of Science, Engineering and Medicine, they're all in support of that. That's something that will hopefully become more routine. Once we have that data and we can start analyzing it and responding to those different needs, I think that's when we'll know how to respond better from a systems level.

You're based in a rural state, in Alabama, and these states have historically been shown to have 

. What are some misconceptions about rural health or COPD in general that you've come across in your career?

 I'm currently in Alabama, and definitely, the Deep South has worse health outcomes compared to many other places. As far as misconceptions are concerned, I don't think that there is a lack of interest in improving your health from a patient standpoint. I don't think that the drive to get healthier is absent.

The truth is, is that there's effects of systemic racism that we're still dealing with down the line. The disadvantages that a lot of our patients have in the Deep South are caused by years and years of dealing with the effects that systemic racism has had. That's something that is a much larger issue to deal with and to reconcile. But I think that the drive to get better health and to get equal opportunities, of course, is still there. I think that's what everyone wants is the opportunity to have a chance at a better life. That specifically refers to equitable opportunities to achieve…a healthy life for our families, a safe home where we can sleep soundly at night, wanting our kids to grow up safe, healthy, and happy. That's what I see with all of my patients, regardless of where they come from, or what socioeconomic class they come from, or what race they are. Everyone wants those basic rights.

The unfortunate part is that many don't have the opportunity to get even close to this. There's a lot of work to be done, but hopefully research like this in the South, research in disadvantaged communities, will be putting us one more step in the right direction.

Is there anything we did not touch on that you'd like to include, or do you have any final thoughts you'd like to share?

 Work in social determinants of health is really, really important. It's an overlooked area that I think we don't have the luxury of overlooking anymore. We’re seeing one example after the next, whether it's in COPD, or with COVID-19, or with natural disasters, or climate change. Communities who are socially disadvantaged will always be hit first and be hit hardest. If you take a look at what's going on in Texas right now, which is where I'm from, the storm hit, and power has been out for several days in some neighborhoods. Now residents are being told they can't use water. Who are the people who are going to be hit hardest here? It's your low-income communities, your predominantly Black and brown neighborhoods, those who have already struggled with feeding their children or keeping them warm. Those who don't have a car to warm up in or family members in nicer neighborhoods to take shelter in. It's a pattern that we see everywhere. I think it's way past time that we start addressing some of these issues, and start focusing on health equity, because it's not going to go away on its own.

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