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Association of low income with pulmonary disease progression in smokers with and without chronic obstructive pulmonary disease

Katherine E. Lowe, Barry J. Make, James D. Crapo, Gregory L. Kinney, John E. Hokanson, Victor Kim, Anand S. Iyer, Surya P. Bhatt, Karin F. Hoth, Kristen E. Holm, Robert Wise, Dawn DeMeo, Marilyn G. Foreman, Thomas J. Stone, Elizabeth A. Regan , for the COPDGene Investigators
ERJ Open Research 2018 4: 00069-2018; DOI: 10.1183/23120541.00069-2018
Katherine E. Lowe
1Dept of Medicine, National Jewish Health, Denver, CO, USA
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  • For correspondence: Katlowe10@gmail.com
Barry J. Make
1Dept of Medicine, National Jewish Health, Denver, CO, USA
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James D. Crapo
1Dept of Medicine, National Jewish Health, Denver, CO, USA
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Gregory L. Kinney
2Dept of Epidemiology, Colorado School of Public Health, Aurora, CO, USA
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John E. Hokanson
2Dept of Epidemiology, Colorado School of Public Health, Aurora, CO, USA
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Victor Kim
3Dept of Thoracic Medicine and Surgery, Temple University, Philadelphia, PA, USA
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Anand S. Iyer
4Dept of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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Surya P. Bhatt
4Dept of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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Karin F. Hoth
5Dept of Psychiatry, University of Iowa, Iowa City, IA, USA
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Kristen E. Holm
1Dept of Medicine, National Jewish Health, Denver, CO, USA
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Robert Wise
6Dept of Medicine, Johns Hopkins University, Baltimore, MD, USA
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Dawn DeMeo
7Dept of Medicine, Brigham and Women's Hospital, Boston, MA, USA
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Marilyn G. Foreman
8Morehouse School of Medicine, Atlanta, GA, USA
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Thomas J. Stone
9Brigham Young University, Provo, UT, USA
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Elizabeth A. Regan
1Dept of Medicine, National Jewish Health, Denver, CO, USA
2Dept of Epidemiology, Colorado School of Public Health, Aurora, CO, USA
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  • FIGURE 1
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    FIGURE 1

    COPDGene consort diagram.

  • FIGURE 2
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    FIGURE 2

    Income status by Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage. Higher- and low-income status was identified for phase 2 subjects who reported annual income based on income >USD 15 000 (higher) and <USD 15 000 (low). Percentage of subjects in higher- and low-income categories is shown for each GOLD stage. In general, the distribution of income status is similar across the GOLD stages except for an excess of low-income subjects in the preserved ratio impaired spirometry group and fewer in GOLD stage 1.

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  • TABLE 1

    Demographics and baseline disease severity

    Low-income smokers (<USD 15 000 per year)Higher-income smokers (>USD 15 000 per year)p-value
    Subjects n15493277
    Age years55.7±7.461.7±8.5)<0.0001
    African American5716<0.0001
    Male49520.031
    BMI kg·m−229.1±6.729.1±5.70.95
    More than high-school education4577<0.0001
    ATS pack-years42.5±25.042.2±22.60.66
    Age started smoking years16.7±5.117.2±4.10.0016
    Current smoking status7336<0.0001
    Using respiratory medications4231<0.0001
    FEV1 % pred78.4±23.280.4±23.00.0042
    FVC % pred87.7±17.889.6±16.50.0002
    FEV1/FVC0.70±0.140.68±0.140.0003
    Percentage emphysema LAA@-950 HU4.68±7.66.24±8.9<0.0001
    Percentage gas trapping LAA@-856 HU19.3±17.920.5±17.80.0652
    Airway wall thickness mm1.063±0.2311.018±0.211<0.0001

    Data are presented as mean±sd or %, unless otherwise stated. BMI: body mass index; ATS: American Thoracic Society; FEV1: forced expiratory volume in 1 s; FVC: forced vital capacity; LAA: low-attenuation areas.

    • TABLE 2

      Symptoms, function and quality of life

      Low-income smokers (<USD 15 000 per year)Higher-income smokers (>USD 15 000 per year)p-value
      Phase 1
       Chronic bronchitis2214<0.0001
       mMRC score1.58±1.460.93±1.24<0.0001
       mMRC score >24928<0.0001
       Severe exacerbation within the past year137<0.0001
       SGRQ total31.74±23.319.3±18.8<0.0001
       6MWD feet1297±3811486±352<0.0001
       SF-36 PCS42.0±11.247.1±10.0<0.0001
       SF-36 MCS45.95±12.652.4±9.8<0.0001
      Phase 2
       Chronic bronchitis2013<0.0001
       mMRC1.64±1.510.99±1.29<0.0001
       mMRC score >25231<0.0001
       Severe exacerbation within the past year147<0.0001
       SGRQ total31.79±23.119.6±19.0<0.0001
       6MWD feet1168±4381356±420<0.0001
       SF-36 PCS39.9±11.445.3±10.6<0.0001
       SF-36 MCS48.0±11.753.6±9.5<0.0001
       CAT score15.0±9.210.5±7.7<0.0001

      Data are presented as % or mean±sd, unless otherwise stated. mMRC: modified Medical Research Council; SGRQ: St George's Respiratory Questionnaire; 6MWD: 6-min walking distance; SF-36: Medical Outcomes Study 36-item short-form questionnaire; PCS: physical component summary; MCS: mental component summary; CAT: Chronic Obstructive Pulmonary Disease Assesment Test.

      • TABLE 3

        Socioeconomic factors beyond income

        Low-income smokers (<USD 15 000 per year)Higher-income smokers (>USD 15 000 per year)p-value
        Education beyond high school4577<0.0001
        Residence
         Own home1970<0.0001
         Rent5922<0.0001
         Lack a permanent home50.5<0.0001
        Have health insurance9097<0.0001
        Access to preventative care
         Get preventative care from doctor/clinic8897<0.0001
         Get preventative care from emergency room81<0.0001
         Do not get preventative care42<0.0001
        Lack a primary-care physician93<0.0001
        Have access to internet5589<0.0001
        Exposures
         Worked in a dusty job5440<0.0001
         Worked in a fumes-related job4945<0.0001

        Data are presented as %, unless otherwise stated.

        • TABLE 4

          Accommodation to healthcare costs

          Low-income smokers (<USD 15 000 per year)Higher-income smokers (>USD 15 000 per year)p-value
          In the last year, because of the expense or lack of coverage, have you …
           Not gone to your doctor when you needed to115<0.0001
           Not filled a prescription106<0.0001
           Stretched out a prescription medication by taking less of it or less often than it was prescribed970.005
           Not gone to the hospital when you needed to61<0.0001
           Gone to an emergency room to be treated92<0.0001
           One or more of the above2514<0.0001

          Data are presented as %, unless otherwise stated.

          • TABLE 5

            Adjusted relationships of income to baseline computed tomography measures

            Coefficient (95% CI)p>|t|
            Baseline emphysemaModel R2 0.3287
             Baseline FEV1−5.91 (−6.24– −5.58)<0.0001
             Height0.15 (0.11–0.18)<0.0001
             Current smoking−2.95 (−3.47– −2.44)<0.0001
             Female−4.16 (−4.80– −3.53)<0.0001
             Age at recruitment−0.075 (−0.11– −0.042)<0.0001
             Education beyond high school−0.91 (−1.42– −0.40)<0.0001
             Lower income−0.82 (−1.37– −0.27)0.004
             African American−2.21 (−2.81– −1.61)<0.0001
             Smoking pack-years0.012 (0.0023–0.022)0.015
            Baseline gas trappingModel R2 0.4874
             Baseline FEV1−14.67 (−15.30– −14.03)<0.0001
             Height0.39 (0.33–0.46)<0.0001
             Current smoking−3.92 (−4.93– −2.92)<0.0001
             Female−9.78 (−11.02– −8.54)<0.0001
             Age at recruitment0.74 (0.011–0.14)0.022
             Education beyond high school−1.38 (−2.36– −0.37)0.007
             Lower income1.00 (−0.089–2.10)0.072
             African American−5.19 (−6.40– −3.99)<0.0001
             Smoking pack-years0.023 (0.0031–0.042)0.023
            Baseline airway wall thicknessModel R2 0.2928
             Baseline FEV1−0.10 (−0.11– −0.095)<0.0001
             Height0.0036 (0.0027–0.0045)<0.0001
             Current smoking0.080 (0.066– 0.094)<0.0001
             Female−0.18 (−0.20– −0.17)<0.0001
             Age at recruitment−0.0020 (−0.0028– −0.0011)<0.0001
             Education beyond high school−0.018 (−0.032– −0.0048)0.008
             Lower income0.021 (0.0062– 0.036)0.005
             African American−0.07 (−0.083– −0.051)<0.0001
             Smoking pack-years0.00069 (0.00042–0.00095)<0.0001

            FEV1: forced expiratory volume in 1 s.

            • TABLE 6

              Income status and 5-year change in spirometry, dyspnoea, health-related quality of life and imaging characteristics

              Low-income smokers (<USD 15 000 per year)Higher-income smokers (>USD 15 000 per year)p-value
              FEV1 % pred−3.26±12.9−1.40±10.1<0.0001
              FEV1 mL−225.6±342−202.1±2800.0115
              FEV1 mL per year−40.0±61.5−35.9±50.00.0142
              Loss of >300 mL in FEV1 n (%)570 (36.8%)1055 (32.19%)0.002
              mMRC dyspnoea score#0.0575±1.430.0649±1.140.87
              SGRQ total score0.0442±19.50.298±13.20.6
              Distance walked feet¶−130±401−128±3350.82
              Adjusted lung density+−1.90±12.1−0.35±11.50.0003
              Emphysema+ %0.677±3.740.06±3.95<0.0001
              Gas trapping§ %2.31±9.520.623±8.17<0.0001
              Airway wall thickness mm−0.0061±0.137−0.0025±0.1080.409
               Current smokers−0.0051−0.0170.083
               Former smokers−0.00860.00510.0291

              Data are presented as mean±sd, unless otherwise stated. FEV1: forced expiratory volume in 1 s; mMRC: modified Medical Research Council; SGRQ: St George's Respiratory Questionnaire. #: n=1547 (low income), n=3271 (higher income); ¶: n=1503 (low income), n=3234 (higher income); +: n=1085 (low income), n=2489 (higher income); §: n=828 (low income), n=2133 (higher income).

              • TABLE 7

                Associations of income and education to disease progression

                Coefficient (95% CI)p-value
                Change in FEV1 mLModel R2 0.0660
                 Baseline FEV1 % pred−2.78 (−3.13– −2.41)<0.0001
                 Current smoking−51.36 (−70.99– −31.73)<0.0001
                 Female68.47 (51.85–85.09)<0.0001
                 Age at recruitment−0.39 (−1.54–0.77)0.51
                 Education beyond high school−7.96 (−27.00–11.08)0.41
                 Low income−36.58 (−57.23– −15.93)0.001
                 African American race49.21 (27.48–70.93)<0.0001
                 Smoking pack-years−0.89 (−1.27– −0.51)<0.0001
                Change in emphysemaModel R2 0.0925
                 Baseline emphysema−0.017 (−0.035–0.00073)0.060
                 Baseline FEV1 % pred−0.051 (−0.058– −0.045)<0.0001
                 Current smoking0.68 (0.39–0.98)<0.0001
                 Female−0.039 (−0.29–0.21)0.76
                 Age at recruitment−0.0057 (−0.023–0.011)0.51
                 Education beyond high school0.21 (−0.075–0.49)0.15
                 Low income0.14 (−0.17–0.45)0.39
                 African American race0.31 (−0.019–0.64)0.065
                 Smoking pack-years0.0051 (−0.00070–0.011)0.085
                Change in airway wall thicknessModel R2 0.1121
                 Baseline airway wall thickness−0.20 (−0.22– −0.18)<0.0001
                 Baseline FEV1 % pred−0.00018 (−0.00036– −0.0000048)0.044
                 Current smoking0.0060 (−0.0029–0.015)0.185
                 Female−0.022 (−0.030– −0.014)<0.0001
                 Age at recruitment0.00070 (0.00019–0.0012)0.008
                 Education beyond high school−0.0013 (−0.0099–0.0073)0.76
                 Low income0.013 (0.0036–0.022)0.007
                 African American race−0.015 (−0.025– −0.0050)0.003
                 Smoking pack-years0.00013 (−0.000042–0.00031)0.136

                FEV1: forced expiratory volume in 1 s.

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                Association of low income with pulmonary disease progression in smokers with and without chronic obstructive pulmonary disease
                Katherine E. Lowe, Barry J. Make, James D. Crapo, Gregory L. Kinney, John E. Hokanson, Victor Kim, Anand S. Iyer, Surya P. Bhatt, Karin F. Hoth, Kristen E. Holm, Robert Wise, Dawn DeMeo, Marilyn G. Foreman, Thomas J. Stone, Elizabeth A. Regan
                ERJ Open Research Oct 2018, 4 (4) 00069-2018; DOI: 10.1183/23120541.00069-2018

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                Association of low income with pulmonary disease progression in smokers with and without chronic obstructive pulmonary disease
                Katherine E. Lowe, Barry J. Make, James D. Crapo, Gregory L. Kinney, John E. Hokanson, Victor Kim, Anand S. Iyer, Surya P. Bhatt, Karin F. Hoth, Kristen E. Holm, Robert Wise, Dawn DeMeo, Marilyn G. Foreman, Thomas J. Stone, Elizabeth A. Regan
                ERJ Open Research Oct 2018, 4 (4) 00069-2018; DOI: 10.1183/23120541.00069-2018
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