Air Pollution Is a Clinical Issue, FM Doc says

Stephanie Cajigal; Elizabeth A. Joy, MD, MPH


May 05, 2016

Editor's Note:
Air pollution can have direct negative effects on health, including pulmonary and systemic inflammation, oxidative stress, and vascular and endothelial dysfunction. However, the authors of a new editorial published in the Annals of Internal Medicine say that physicians can help patients avoid air pollution.

One of the authors, Elizabeth A. Joy, MD, MPH, medical director for community health at Intermountain Healthcare in Salt Lake City, Utah, recently spoke with Medscape about how she and her colleagues educated themselves about health issues related to poor air quality and turned it into information they now use to counsel patients.

Medscape: How did you become interested in the topic of air quality?

Dr Joy: My interest stemmed from when I moved from Minnesota to Utah about 20 years ago and was stunned that here is this incredibly beautiful place, but it has such bad air quality. Salt Lake City is in a valley between two mountain ranges; this puts us at risk for something called "inversions," where cold air and pollutants are trapped in our lower atmosphere. Because the majority of Utah residents live along the Wasatch Front between Ogden to the north and Provo to the south, there is considerable air pollution from motor vehicles, industry, and residential sources. Combined, these contribute to Utah's poor air quality.

Elizabeth A. Joy, MD, MPH

We have so many public health messages encouraging people to be physically active and to be outside, but they have not been well connected to public health messaging regarding air quality. Our work at Intermountain Healthcare seeks to connect these messages.

About 2 years ago, our Intermountain chief executive officer, Dr Charles Sorenson, asked whether we would bring together a group that would address air quality and health from both a provider education perspective and a patient education perspective. The goal was to educate people about the impact of air quality on various health outcomes in a way that could mitigate its effects.

Medscape: What did you discover in that time?

Dr Joy: Our work is focused on the relationship between poor air quality and health outcomes. We have an outstanding team of clinicians, researchers, and administrators. We have generated patient fact sheets and a care process model for clinicians, and are continuing our research efforts in cardiac and pulmonary disease. In addition, we are expanding our corporate sustainability efforts to limit our organizational carbon footprint.

Medscape: What kind of guidelines did you create in terms of educating patients?

Dr Joy: Our patient fact sheets are all Web-based, so clinicians can access them at the point of care, whether they are in the clinic, a hospital, or an emergency department, and patients and community members can access them from our public facing webpages as well. These fact sheets talk about the relationship between air quality and heart disease or stroke, asthma, and pregnancy.

We use the Environmental Protection Agency's (EPA's) Air Quality Index (AQI) as the guide, and provide specific recommendations with regard to outdoor air exposure in relation to the AQI value. If the air quality is good, we advise people to have unrestricted time outdoors doing exercise or work. As the air quality deteriorates, we have recommendations about how patients should limit their exposure in terms of time and exercise intensity.

We also talk about symptoms that patients may be experiencing as a result of poor air exposure. So if you're an asthma patient, you should use a rescue inhaler, or if you're a patient who might be experiencing signs or symptoms of a heart attack or stroke, you should reach out to a healthcare provider.

Medscape: How strong is the link between air quality and health?

Dr Joy: The link between air quality and adverse health outcomes is strong and is growing stronger. Over a decade of research has demonstrated a link between air pollution and adverse cardiac outcomes, such as myocardial infarction, and a recent publication found that every 15-mg increase in PM2.5 was associated with a 15% increase in ST-segment elevation myocardial infarction.[1]

Likewise, studies have demonstrated both short-term and longer-term adverse pulmonary outcomes, not only for patients with such conditions as asthma and chronic obstructive pulmonary disease, but also among people with otherwise healthy lungs.[2]

Medscape: How do you educate patients about when the air quality is poor?

Dr Joy: We have a very active air quality community in Utah. UCAIR was established by the governor to provide public health education and to sponsor programs aimed at improving the air quality. UCAIR sponsors the AQI updates that appear on the radio and television and in local newspapers. The AQI data come from air quality monitors that are positioned throughout the state. The AQI provides people with the information necessary to determine whether it is safe to take their dog for a walk outside, or push their infant in a stroller.

We are also working to integrate the AQI into our electronic health record. This is particularly important for physicians caring for high-risk populations, such as infants, adults and children with asthma, adults with a history of heart disease or stroke, or patients with heart failure. Our hope is that seeing the AQI in the health record will prompt a discussion between physician and patient about how air quality may affect health and health behaviors.

Medscape: Do you feel that it's a physician's responsibility to go out of his or her way to alert patients about air quality, or is it just something to bring up during the patient encounters?

Dr Joy: We are discussing various options aimed at keeping patients more aware of the air quality (aside from looking out their window!). We encourage patients to download the EPA's app so that they can monitor the air quality in their own zip code.

Medscape: During periods of poor air quality in your area, do you notice patients coming in with certain symptoms? Is it easy to make the connection between the two?

Dr Joy: Yes, absolutely. I have had patients come in complaining of shortness of breath, burning throat and eyes, and nasal congestion as a result of exposure to poor air quality. Our care process model provides information to clinicians about signs and symptoms related to both short-term and long-term (repeated) exposure to poor air quality.

One of the challenges we face is that exposure to some air pollution (eg, ozone) is largely asymptomatic. Ground-level ozone is largely undetectable in terms of signs and or symptoms, yet it can induce significant inflammation in the lungs and vasculature.

Medscape: Do you find that patients are able to make some changes to their routines to limit their exposure?

Dr Joy: I've had a somewhat mixed experience. I've had patients come in and it's in the middle of the winter, and they know that their asthma is worse because of air quality. We talk about different inhalers for them to use. I might give them a steroid inhaler to try to reduce the airway inflammation. We talk about exercising indoors rather than going for a run on a trail or in a park when the inversions are bad. We talk about running at a higher altitude, where the air quality tends to be better.

The challenge is the patient who has little control over their air quality exposure—for example, a pregnant woman who has to walk six blocks to catch the bus every morning, and six blocks home at the end of the day. How is she supposed to change her exposure when she has limited options for transportation?

Some patients have asked about wearing a facemask for protection. Although we do not advocate for this in our care process model, I acknowledge that some facemasks (eg, an N95 mask) may provide some protection against particulate pollution.

One of Intermountain's cardiologists has been distributing the Air Quality and Heart Disease Patient Fact Sheet to his patients, and he reports that the response has been overwhelmingly positive and that patients are grateful that he cares enough to educate them about this.

Medscape: Many doctors are already overwhelmed with their day-to-day responsibilities that thinking about educating patients about air pollution may seem like too much to fit into their workloads. How do you get your colleagues to care about something that might not have an immediate impact on their patients?

Dr Joy: It is no surprise to any physician in Utah, and especially to those practicing along the Wasatch Front, that we have an air quality problem. Likewise, owing to the efforts of many air quality advocacy groups, they are aware that poor air quality affects health. Providing clinicians with information, tools, and processes that can support their efforts in discussing air quality and health makes it easy for them to do the right thing. Our patient education materials are embedded in our care process model, making them only a click away from providing meaningful and actionable information to patients at the point of care.

Medscape: What about doctors in other areas where the air quality levels aren't broadcast? How do they educate patients?

Dr Joy: When we started our Air Quality and Health Initiative, we looked at other healthcare systems around the country to see what they were doing in the air quality and health space; however, we found very little. Our hopes are that other healthcare systems will find the tools we have developed helpful in their efforts at addressing air quality and health outcomes.

Medscape: According to a recent report from the American Lung Association, more than one half of the US population lives in areas that have unhealthy levels of either ozone or particle pollution. Do you see this as a clinical issue?

Dr Joy: Absolutely; the evidence is incontrovertible regarding the negative impact of ozone and particulate pollution on health. There is a saying that "genetics loads the gun, and environment pulls the trigger." This statement is no doubt true with regard to air pollution. Some people will probably be affected more than others, but chronic exposure to air pollution negatively affects the health of everyone. We cannot ignore it, and we have to take steps to not only reduce poor air quality, but also to protect ourselves and our family members to the greatest extent possible.


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