COPD Spotlight - Episode 4
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 The American Journal of Managed Care® (AJMC®), 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.
The following interview has been edited for length and clarity.
AJMC®: What are some of the social determinants of health commonly associated with poor outcomes among patients with COPD?
Parekh: 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.
AJMC®: A study 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?
Parekh: 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.
AJMC®: You're the lead investigator of a 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?
Parekh: 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 (SPIROMICS) 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.
AJMC®: 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?
Parekh: 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.
AJMC®: You're based in a rural state, in Alabama, and these states have historically been shown to have higher rates of chronic disease. What are some misconceptions about rural health or COPD in general that you've come across in your career?
Parekh: 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.
AJMC®: 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?
Parekh: 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.