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(Chest. 1999;116:306-313.)
© 1999 American College of Chest Physicians

Trends in the Epidemiology of COPD in Canada, 1980 to 1995*

Yves Lacasse, MD, MSc; Dina Brooks, PhD; Roger S. Goldstein, MB, ChB, FCCP, and for the COPD and Rehabilitation Committee of the Canadian Thoracic Society

* From the Centre de Pneumologie (Dr. Lacasse), Hôpital Laval, Ste-Foy, Québec, Canada; and the Department of Physical Therapy (Drs. Brooks and Goldstein), and the Department of Medicine (Dr. Goldstein), University of Toronto, Ontario, Canada.

Correspondence to: Yves Lacasse, MD, MSc, Centre de Pneumologie, Hôpital Laval, 2725 Chemin Ste-Foy, Ste-Foy, P. Québec G1V 4G5, Canada; e-mail: lacassey{at}videotron.ca


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
 References
 
Purpose: To describe trends in the epidemiology of COPD in Canada from 1980 to 1995, in terms of perceived prevalence, mortality, and hospital morbidity.

Data sources: We limited the analysis to data related to chronic bronchitis, emphysema, or chronic airway obstruction not classified elsewhere, and excluded asthma (Ninth International Classification of Diseases, codes 490 to 492 and 496). The perceived prevalence rate of COPD was derived from the 1994–1995 National Health Survey. Mortality and hospital morbidity data (from 1980 to 1995) were obtained from the Health Statistics Division of Statistics Canada.

Results: From the National Health Survey, it was estimated that 750,000 Canadians had chronic bronchitis or emphysema diagnosed by a health professional. Prevalence rates were the following: ages 55 to 64 years, 4.6%; ages 65 to 74 years, 5.0%; >= 75 years, 6.8%. From 1980 to 1995, the total number of deaths from COPD increased from 4,438 to 8,583. Although the age-standardized mortality rate remained stable throughout this period in men (around 45/100,000 population), it doubled in women (8.3/100,000 in 1980 to 17.3/100,000 in 1995). There were 55,782 hospital separations in 1993–1994 with COPD as the primary discharge diagnosis (compared to 42,102 in 1981–1982). In people aged >= 65 years, the age-specific hospital separation rate increased over this period, especially in women >= 75 years (from 504/100,000 to 1,033/100,000). The average in-hospital length of stay was 9.6 days in 1981–1982 and 8.3 days in 1993–1994.

Conclusion: COPD represents a major health issue in Canada and will likely remain so for decades. Physician and non-physician health professionals who provide health care, as well as those who fund it must actively encourage approaches for primary and secondary prevention of this condition as well as approaches shown to be effective in addressing its associated impairment, disability, and handicap.

Key Words: COPD • epidemiology • morbidity • mortality • prevalence rate


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 Conclusion
 References
 
Since 1960, there has been an increase in the mortality associated with COPD, especially in men. This increase could not be explained by a change in coding or diagnostic practices. It has been associated with the continued use of cigarettes and has affected all those aged > 35 years.1 The increase in mortality among women has lagged behind men by about 15 years, largely reflecting differences in smoking patterns between the genders. Several strategies have been recommended to reduce the burden of COPD. Strategies for primary or secondary prevention include smoking cessation2 and regular immunization against influenza.3 The former, addressing the principle cause of COPD,4 is very likely to influence the natural history of this condition, whereas the influence of the latter has not been clearly determined. Other strategies for disease management include regular or as-needed use of bronchodilators,5 oral antibiotics in acute exacerbations of the disease,6 and respiratory rehabilitation.7 Though for some individuals one or more of these approaches may improve the course of COPD, their overall impact on hospital morbidity or disease-related mortality is unknown.

In 1988, a National Institute of Health-sponsored workshop8 was established to summarize what was known about COPD mortality trends in the United States. In this workshop, Manfreda and colleagues9 presented information drawn from the Canadian National Mortality Database regarding the mortality and morbidity of COPD (including asthma) in Canada between 1950 and 1984. Their results suggested that the increase in mortality from COPD had leveled off among men but was still increasing among women. Prevalence estimates for COPD were also generated in 1978–1979 from a health survey conducted by Health and Welfare Canada in conjunction with Statistics Canada.10

In this report, we extend these observations to describe the epidemiology of COPD in Canada in terms of perceived prevalence, mortality, and hospital morbidity during the period from 1980 to 1995. The continued high burden of this disease among Canadians means that it remains a major consumer of health-care resources, which emphasizes the importance of encouraging behaviors and policies designed to prevent COPD, as well as using the most cost-effective approaches in managing its complications.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 Conclusion
 References
 
Data Sources
Data were obtained for the period from 1980 to 1995 with the cooperation of the Health Statistics Division of Statistics Canada. The data supplied included the prevalence, mortality, and hospital morbidity from COPD.

Prevalence: Estimates of the point prevalence of COPD were derived from the 1994–1995 National Population Health Survey conducted by Statistics Canada.11 The target population of this survey included household residents in all provinces,with the principal exclusion of the population on Indian reserves, Canadian Forces bases, and some remote areas in Quebec and Ontario. A stratified two-stage design was used to survey households. In the first stage, homogeneous geographic and/or socioeconomic strata were formed, and independent samples of clusters were drawn from each stratum with probability proportional to size. In the second stage, dwelling lists were prepared for each cluster, and dwellings (households) were selected from the lists to form the study population. Most respondents were first contacted in person. Many interviews were completed by telephone because the selected respondent was not available at the time of the initial visit or because the long interview time prevented the completion of the interview in one contact.

The approach taken by the survey staff involved collecting limited information on all the members residing in a particular household and then randomly selecting one individual aged >= 12 years for an in-depth interview. In all dwellings, some of the information about all the household members was obtained from a knowledgeable household member, usually the person at home at the time of the interviewer's visit. Such "proxy reporting" accounted for approximately 55% of the information collected for the survey, including the information regarding chronic conditions such as COPD. Estimates of the prevalence of COPD were derived from the individual's response to the following question: "Do you have chronic bronchitis or emphysema diagnosed by a health professional?"11 The respondents' answers were not validated by further investigation. Since the prevalence rates reported in this study come from a self-report survey, the information reported should be thought of as the perceived prevalence.

Mortality: All deaths occurring in Canada are included by law in the vital statistics death registration system.12 Thus, mortality statistics provided by Statistics Canada are not estimates. The cause of death coded and tabulated on the Statistics Canada National Mortality Database is the underlying cause of death, which is defined as either (1) the disease or injury that initiated the train of events leading directly to death, or (2) the circumstances of the accident or violence that produced the fatal injury. This underlying cause of death is selected from a number of conditions listed on the death certificate. Only the underlying cause of death is captured. The information on causes of death is coded and tabulated according to the ninth revision of the International Classification of Diseases (ICD-9).13 The ICD-9 terminology has been in use in Canada since 1979. We selected codes (Table 1 ) matching the terms "bronchitis" (code 490), "chronic bronchitis" (code 491), "emphysema," (code 492), or "chronic airway obstruction, not elsewhere classified" (code 496), and excluded from consideration the following causes: "asthma" (code 493); "bronchiectasis" (code 494); and "extrinsic allergic alveolitis" (code 495). ICD-9 code 496 ("chronic airway obstruction, not elsewhere classified") is used when clinicians enter "COPD" as the cause of death on the death certificate or as the primary diagnosis following their patients' discharge. We could not separate the influence of COPD as the primary cause of death from the influence of COPD as a contributing cause of death, since the National Mortality Database only codes for the primary cause of death.


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  		Table 1. ICD-9 Descriptions and Codes of COPD and Allied Conditions

 
Hospital Morbidity: National hospital morbidity statistics are retrieved by Statistics Canada from hospital medical records departments who identify "hospital separations," each of which represents the end point of one continuous stay in the hospital for a patient.14 The data do not include individuals treated as outpatients. At the end of each stay, the patient is "separated," being discharged, deceased, or transferred to another institution. Because a patient may be admitted to and discharged from a hospital several times during the year, these statistics are a count of cases rather than of individual persons.14 The cases are identified by "primary diagnosis." The in-hospital length of stay is also recorded. For the hospital separations, we analyzed the same ICD-9 codes as for the mortality analysis.

Statistics
Prevalence: The National Population Health Survey was budgeted for a sample size of 19,600 households. It was further agreed among national and provincial representatives that each province needed to include a minimum of 1,200 households. Subject to this restriction, the provincial sample sizes were obtained using an allocation scheme that balanced the reliability requirements at national and regional levels. According to this scheme, the sample was allocated according to the 1991 census proportion of households in each province. A total of 17,626 individuals were surveyed, which represented a 96.1% response rate.11 The prevalence estimates obtained from the survey were weighted according to the inverse probability of selecting a cluster (cluster weight) and the inverse probability of selecting a dwelling, given that the cluster which contains it is selected (dwelling weight). The "basic weight" obtained from the product of the cluster weight and the dwelling weight was then adjusted according to other minor design features of the survey. Confidence intervals (95%) around the prevalence rates were calculated from their variance, which was estimated using the "jack-knife" method. In this method, the estimate of the variance of the parent sample is derived from the variability among the variance of subsample estimates.15 Throughout the analysis, we considered groups aged 55 to 64 years, 65 to 74 years, and >= 75 years.

Mortality: We reported the annual mortality as (1) the absolute number of deaths, (2) the age-standardized mortality rate, and (3) the age-specific mortality rates. Age-standardized mortality rates relate the number of deaths (per 100,000 population) to the population that would have occurred if the age distribution of that population were the same as that of the standard population at a particular time. Mortality rates were standardized to the 1991 Canadian population. In order to facilitate a comparison between the current age-standardized mortality rates and those previously presented by Manfreda et al9 (mortality trends between 1950 and 1984), we also standardized all mortality rates to the 1971 Canadian population. Data are presented separately for men and women.

Morbidity: We reported the annual hospital morbidity statistics in the following ways: (1) as the total number of separations; (2) as the age-standardized separation rate per 100,000 population (standardized to the 1991 population); and (3) as age-specific separation rates. We calculated the average length of stay by dividing the total number of days in the hospital by the total number of separations. Since hospital morbidity data also included separations from long-term care facilities, we excluded hospital stays > 30 days in order to reflect the situation in acute-care hospitals only. Data for men and women are again presented separately.


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 Conclusion
 References
 
Prevalence of COPD
The household survey estimated that almost three quarters of a million (749,714) Canadians had chronic bronchitis or emphysema diagnosed by a health professional. Prevalence rates according to gender and age-groups are presented in Table 2 . In each of the three major age categories, the prevalence of COPD was higher among men than among women. For the population as a whole, the prevalence increased with age, the highest prevalence being recorded among men > 75 years old.


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  		Table 2. Prevalence Rates of COPD in Canada, 1994 to 1995*

 
COPD-Related Mortality
In 1980, COPD accounted for 2.6% of all deaths in Canada (3.6% in men and 1.3% in women). By 1995, the proportion had risen to 4.1% (4.6% in men and 3.3% in women). The actual number of deaths from COPD between 1980 and 1995 is shown in Figure 1 , top, A. The rise in mortality was especially noticeable among women, among whom deaths increased by 241% (from 967 to 3,295).



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  		Figure 1. Mortality from COPD in Canada, from 1980 to 1995. Top, A: total number of deaths for men, women, and both genders. Bottom, B: age-standardized mortality rate (per 100,000 population) for men, women, and both genders.

 
The age-standardized mortality rates are shown in Figure 1 , bottom, B. In men, the rate remained relatively stable throughout this period at 45 per 100,000, whereas in women it increased from 8.3 per 100,000 in 1980 to 17.3 per 100,000 by 1995. The data reported by Manfreda et al9 can be compared with the 1984-to-1994 death rates from COPD by standardizing the latter to the 1971 Canadian population (Fig 2 ). Of note, the data from Manfreda et al9 also included mortality from asthma. However, asthma-related mortality did not account for the changes observed between 1984 and 1994, since the asthma-related mortality rate decreased both in men and women during this period. The mortality rate from COPD among women has increased steadily since the early 1960s and by 1994 had not leveled off.



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  		Figure 2. Age-standardized mortality rates (per 100,000 population) for COPD (including asthma) in Canada, 1951 to 1994. All mortality rates were adjusted for the 1971 Canadian population. Left, A: mortality rate, 1951 to 1983. Reproduced from Manfreda et al,9 with permission. Right, B: mortality rate, 1984 to 1994.

 
The age-specific death rates are shown in Table 3 . Although the overall death rates (for both men and women) remained stable in the age categories 55 to 64 years and 65 to 74 years, the age-specific death rate decreased among men, whereas it increased among women. Between 1980 and 1995, the age-specific death rates increased for men and women aged >= 75 years.


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  		Table 3. Age-Specific Death Rates (per 1,000 Population) From COPD in Canada, 1980 to 1995

 
Hospital Morbidity From COPD
Hospital separations between 1981–1982 and 1993–1994 are shown in Figure 3 . Figure 3 , top, A, shows the total number of hospital separations for men and women. The total number of separations in which COPD was the primary diagnosis increased by 32% (from 42,102 to 55,785). This comprised a 14% increase among men and a 67% increase among women. Figure 3 , bottom, B, shows the age-standardized separation rate per 100,000 population for men and women. The separation rate slightly decreased in men, whereas it increased by 25% in women. The age-specific separation rates (per 100,000 population) are shown in Table 4 . The decline in separation rates among men aged 55 to 64 years and 65 to 74 years was mirrored by an increase in separation rates among women during the same period. In both genders, there was an increase in separations for those aged >= 75 years.



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  		Figure 3. Hospital morbidity from COPD in Canada, from 1981 to 1994. Top, A: total number of hospital separations for men, women, and both genders. Bottom, B: age-standardized hospitalization rate (per 100,000 population) for men, women, and both genders.

 

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  		Table 4. Age-Specific Hospital Separation Rate (per 100,000 Population) From COPD in Canada, 1981 to 1994

 
In patients aged >= 55 years, the average length of stay for COPD-related hospitalizations was 9.6 days in 1981–1982 and 8.3 days in 1993–1994. The average length of stay decreased by > 1 day from 1981 to 1994 in all age groups (Fig 4 ), so that the average length of stay in patients aged >= 75 years was about the same as it was in 1981–1982 for patients aged 55 to 64 years. As expected, the length of stay increased with the patients' age.



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  		Figure 4. Average length of in-hospital stay primarily related to COPD, 1981 to 1994.

 

   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
Conclusion
 References
 
Changes in clinical practice and disease classification make it important to understand the real changes in prevalence, mortality, and morbidity from COPD. Comparison with similar information from other countries is hampered both by the updating of the ICD (now in its ninth version) and by the inclusion of asthma (ICD-9, code 493) in many reports of COPD.9 16 In order to obtain a clearer picture of the impact of COPD, we excluded from the analysis those with a diagnosis of asthma.

Data Quality
The survey methods reflect several limitations in data collection, including the computation of prevalence rates from a self-report survey. If individuals with nonobstructive bronchitis were included, then the survey might have overestimated the true prevalence of COPD in the community. However, as the survey could not capture individuals with undiagnosed illnesses or those unaware of their diagnosis, the true prevalence might have been underestimated. The direction of the bias, if any, is uncertain. The consideration of COPD as the primary cause of death only resulted in the omission of any impact of COPD on health if it were present as a secondary or contributing diagnosis. Inaccuracies in the diagnosis or in chart completion (or transcription) might also have resulted in inaccurate hospital morbidity information.

Although the diagnosis of COPD is useful for delineating the epidemiology of this condition, it does not provide more detailed information as to the distribution of emphysema vs chronic bronchitis among COPD sufferers. Such information would be of interest to those who allocate resources specific to one or other of these conditions such as lung volume-reduction surgery for individuals with emphysema.

An important weakness in this estimate of disease morbidity is the absence of outpatient information, such as scheduled or unscheduled medical visits, as well as short stays in hospital emergency departments. Such visits represent important uncaptured data on resource allocations, which assist in reflecting the effect of COPD on morbidity within the community. By excluding patients whose length of stay was > 30 days, we omitted individuals admitted to inpatient pulmonary or geriatric programs. We may also have omitted individuals who required acute care for > 30 days, such as those with acute exacerbations complicated by associated medical conditions.

International Comparisons
COPD represents a major cause of death in most developed countries. Differences in mortality rates have been attributed to problems in comparability of cause-of-death statistics.16 However, until 1985, trends in COPD mortality in Canada had followed those in the United States, England, France, Germany, Belgium, and Australia.16 17

More recently, Mannino et al18 reported on mortality trends among people who died with a diagnosis of obstructive lung disease in the United States from 1979 to 1993. Important differences exist between the methodology used in their study and ours, and these account for differences in results. First, their definition of obstructive lung disease also included asthma (ICD-9, code 493). Second, the authors included deaths for which obstructive lung disease was listed on the certificate but was not necessarily classified as being the underlying cause of death. Not surprisingly, higher age-adjusted obstructive lung disease-related mortality rates were reported (77.5/100,000 in 1993, vs 20.4/100,000 in Canada when obstructive lung disease as the primary cause of death was reported). The authors18 could not determine the importance of obstructive lung diseases in the deaths of those with other primary underlying causes of death. Nevertheless, when they reported the death records that specified obstructive lung disease as the underlying cause of death, mortality rates in the United States and Canada were actually quite similar (1995 United States mortality, 3.6%; 1995 Canadian mortality, 4.1%).

Smoking and COPD
Cigarette smoking is the most important cause of chronic obstructive lung diseases.19 20 The disparity in smoking practices between men and women has been reflected in their respective mortality rates (Fig 2) . Given that women began smoking later than men and given the lag between smoking and death from COPD,21 the delay in the rise in COPD mortality is not surprising. The decline in smoking rates among young Canadians from 1980 to 1990 (Fig 5 ) has been encouraging. However, the rise in the smoking rates observed since 1990 will likely be associated with a rise in the mortality and morbidity from COPD over the next 4 decades.



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  		Figure 5. Smoking prevalence by gender in Canada, 1981 to 1994. Top, A: age 15 to 19 years. Bottom, B: age 20 to 24 years. Reproduced from Health Canada,22 with permission.

 
Burden of COPD
The real burden of COPD is best understood by comparing its indexes of mortality and morbidity with other health conditions. Such data recently became available in a report detailing the causes of mortality and hospitalization among Canadian senior citizens.23 A summary of some of this information is shown in Tables 5 and 6 . For the period from 1984 to 1993, COPD was the fourth-ranked cause of mortality among male Canadians aged >= 65 years and the fourth-ranked cause of hospitalization. Among women aged >= 65 years, COPD was the seventh-ranked cause of death and the sixth-ranked most frequent cause of hospitalization. Given the high disease prevalence, the predilection for individuals in their seventh decade, and the marked impairment, disability, and handicaps associated with advanced disease, information on mortality and hospital morbidity provide only partial information as to the true burden of this condition on Canadians. Costs of medications (including oxygen), hospitalizations, work absenteeism, early retirements, and the overall impact of this condition on health-related quality of life are difficult to estimate precisely and are not reflected in this information.


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  		Table 5. Leading Causes of Death Among Canadians Aged >= 65 Years, 1984 to 1993*

 

   Conclusion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
References
 
This survey suggests that COPD remains an important condition among Canadians and will likely continue to be for many years to come. Primary prevention among teenagers through strong media campaigns is most likely to influence the trends in the epidemiology of the disease. However, detailing the potential long-term health consequences of smoking (such as lung cancer and emphysema) is one of the least effective strategies that has been used in antismoking advertising campaigns, especially with youth.24 Rather, the data we report in this article should challenge those who fund and provide health care to identify and implement the best approaches to the prevention as well as the management of this common condition. These strategies include continuing antismoking campaigns (primary prevention), early detection and intervention for those individuals at risk for the late consequences of COPD (secondary prevention),25 and the widespread application of effective therapeutic modalities in reducing the complications of the disease (tertiary prevention).


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  		Table 6. Leading Causes of Hospitalization Among Canadians Aged >= 65 Years, 1983 to 1992*

 

   Acknowledgements
 
The authors thank Mr. Garry MacDonald from the Health Statistics Division of Statistics Canada and Mr. Larry Swain, project manager of the 1994–1995 National Population Health Survey, for their assistance in providing the data, and Dr. François Maltais for his helpful comments, as well as his support in preparing the figures.


   Footnotes
 
Supported by the Canadian Lung Association, the Canadian Thoracic Society, West Park Hospital Foundation, and Boehringer Ingelheim (Canada), Inc.

Abbreviations: ICD-9 = ninth revision of the International Classification of Diseases

Received for publication May 22, 1998. Accepted for publication February 24, 1999.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
 References
 

  1. Speizer, FE (1989) The rise in chronic obstructive pulmonary disease. Overview and summary. Am Rev Respir Dis 140,S106-S107
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  8. Speizer, FE (1989) The rise in chronic obstructive pulmonary disease. Introduction. Am Rev Respir Dis 140,S1
  9. Manfreda, J, Mao, Y, Litven, W (1989) Morbidity and mortality from chronic obstructive pulmonary disease. Am Rev Respir Dis 140,S19-S26
  10. Health and Welfare Canada, Statistics Canada. The Health of Canadians: report of the Canada Health Survey. Ottawa: Ministry of Supply and Services, 1981; Catalogue 82–538E
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  12. Statistics Canada, Health Statistics Division. Causes of death, 1993. Ottawa: Ministry of Industry, 1995; Catalogue 84–208
  13. International Classification of Diseases. 9th revision. Geneva: World Health Organization, 1978
  14. Statistics Canada, Health Statistics Division. Hospital morbidity, 1992–93; Ottawa: Ministry of Industry, 1995; Catalogue 82–216
  15. Wolter, KM (1985) Introduction to variance estimation. ,153 Springer-Verlag New York.
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