title: Influence of country-level differences on COPD prevalence.
abstract: OBJECTIVE
  Studies suggest that COPD prevalence may vary between countries. We conducted an ecological study of data from COPD prevalence articles to assess the influence of differences in country-level risk factors on COPD prevalence.
  
  
  METHODS
  Our study covered English language articles published during 2003-2014. Qualified articles used spirometry to assess COPD prevalence and used representative samples from national or subnational populations. Stepwise binomial regression was used to analyze associations between study- and country-level factors and COPD prevalence.
  
  
  RESULTS
  Eighty articles provided 1,583 measures of COPD prevalence for subjects in different sex, age, and smoking categories for 112 districts in 41 countries. Adjusted prevalence rates for COPD were significantly lower for Australia/New Zealand and the Mediterranean and significantly higher for Latin America, compared to North America, Southeast Asia, and Northern Europe. Country-level socioeconomic development variables had an uneven and mixed association with COPD prevalence. High elevation above sea level was shown to be a protective factor for COPD. Study-level variables for the established risk factors of sex, age, and smoking explained 64% of variability in COPD prevalence. Country-level risk factors raised the explanatory power to 72%. Approximately 28% of worldwide variability in COPD prevalence remained unexplained.
  
  
  CONCLUSIONS
  Our study suggests that COPD prevalence varies across world regions, even after adjustment for established risk factors. Major country-level risk factors contributing to the worldwide epidemic of COPD remain to be investigated.
authors.affiliation: Ottawa Hospital Research Institute, University of Ottawa, Ottawa.
authors.forename: Shawn D
authors.initials: SD
authors.lastname: Aaron
authors.affiliation: Sunnybrook Research Institute, University of Toronto, ON.
authors.forename: Andrea S
authors.initials: AS
authors.lastname: Gershon
authors.affiliation: Ottawa Hospital Research Institute, University of Ottawa, Ottawa.
authors.forename: Yuan
authors.initials: Y
authors.lastname: Gao
authors.affiliation: Ottawa Hospital Research Institute, University of Ottawa, Ottawa.
authors.forename: Jenna
authors.initials: J
authors.lastname: Yang
authors.affiliation: Ottawa Hospital Research Institute, University of Ottawa, Ottawa; Desautels Faculty of Management, McGill University, Montreal, QC, Canada.
authors.forename: G A
authors.initials: GA
authors.lastname: Whitmore
mesh_terms: D000328:Adult; D017677:Age Distribution; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D008168:Lung / Q000503:physiopathology; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D015995:Prevalence; D065840:Protective Factors; D029424:Pulmonary Disease, Chronic Obstructive / Q000175:diagnosis / Q000453:epidemiology* / Q000503:physiopathology; D012044:Regression Analysis; D012307:Risk Factors; D012720:Severity of Illness Index; D017678:Sex Distribution; D012907:Smoking / Q000009:adverse effects / Q000453:epidemiology; D016540:Smoking Cessation; D000074606:Smoking Prevention; D013147:Spirometry; D013997:Time Factors
keywords: country effects; ecological study; epidemiology; lung disease; risk factors; spirometry