Discussion
This large online survey of the experience of people living with COPD provides important contemporary data on the role that socioeconomic factors may play in AECOPD. We found that low income, poor housing quality, past occupational exposure to airborne pollutants and current smoking were all significantly associated with higher AECOPD frequency. Current smoking was also associated with an increased risk of AECOPD requiring hospitalisation.
A key objective in COPD care is to reduce the frequency of AECOPD, both to improve patients’ quality of life and to limit as far as possible the avoidable use of finite healthcare resources. However, there is a huge unmet care need among patients with COPD within the UK, with a large proportion of patients missing out on important COPD care such as self-management plans, vaccinations, pulmonary rehabilitation and smoking cessation,5 6 all of which are proven interventions for reducing AECOPD. The COVID-19 pandemic has worsened this unmet need further, as people with respiratory disease have had trouble accessing healthcare.7–9 Asthma + Lung UK survey data show that over 75% COPD patients report not receiving basic care during 2020/2021.4 Switching to a digital by default model, further risks excluding deprived and older patients.
Despite the known link between housing quality and health (particularly excess winter deaths), and the 2015 National Institute for Healthcare and Excellence guidance that recommends that healthcare providers assess housing quality and make referrals where necessary,10 the effect of housing quality on COPD health has been little studied. Current guidance for housing temperature in the winter is a minimum of 18°C,10 but this may not be sufficient for people with COPD. A 2008 paper reported that greater time spent with an indoor temperature ≥21°C was associated with better self-reported health status in people with COPD.11 Of note, data from the Office for Health Improvement and Disparities show that in 2018 2.4 million people in England were living in fuel poverty.1 More than 70% of survey participants fell below the UK median household income of £31 004, and the impact of housing conditions onAECOPD reflects that, though the link with cold / damp housing was independent of income.
It is well established that austerity policies, which have reduced both social and healthcare support, have had significant impact on the most vulnerable in society, in particular people living with long-term health conditions.12 Our findings underline this, with poorer survey respondents almost twice as likely to be in the frequent exacerbator group. This is especially relevant as fuel poverty is increasing, and the results illustrate several aspects of the structural violence (where ‘violence is built into the structure and shows up as unequal life chances’13), to which people with COPD are subject.14
The survey also highlights an important link between smoking, AECOPD frequency and hospitalisations, adding further urgency to the need for strategies to deliver the UK government’s smokefree2030 ambition.15 16
The survey design has some limitations. First, it required some digital literacy, which may have excluded a portion of the COPD population in the UK. Second, there is likely to have been some degree of responder and recall bias. Third, we did not independently validate household income or housing conditions, and we were unable to triangulate index of deprivation as we did not have postcode data. However, we believe that the use of household income as a measure of SES is a robust approach. In addition, the survey population was overwhelmingly white, so caution is needed extrapolating to other ethnic groups, and positive efforts to capture their experience are needed in the future. Finally, the studied cohort are likely to be individuals who were motivated to engage with online surveys and the Asthma + Lung UK charity. These factors may limit generalisability of the findings and may have led to an underestimate of the true impact on SES and housing quality on AECOPD.
In conclusion, these data add to the growing evidence that socioeconomic status, in particular poor housing conditions, are linked to increased frequency of AECOPD. Addressing social deprivation, with a multiagency approach at national and local government level and across health and social care is essential to reduce inequalities and treat the causes of the causes of AECOPD in the UK. In doing so, this will improve the sustainability of healthcare and improve the lives of people with COPD across the UK.
