Chronic Cough Patient Identification: Symptom Presentation Differences and Social Determinants of Health

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Dr. Taliercio:
Hello, my name is Rachel Taliercio. I'm from Cleveland Clinic. This presentation will review the social determinants of health and population differences in the presentation of chronic cough. Chronic cough is very common. Prevalence estimates range from three to 40% depending on the population. On average, chronic cough is defined as a cough of eight weeks or more, affects roughly 10% of all adults. Cough as a symptom is the most common reason patients seek care in the outpatient setting. Up to 40% of patients with a chronic cough have refractory or unexplained cough. Cough can cause a great deal of distress for patients. Physical complications are common and include sleep disturbance, stress urinary incontinence, syncope, and even vomiting. Cough impacts the social domain. In order to try and control the cough, patients will commonly avoid social gatherings. There's an economic burden as well. Patients with chronic cough have a much higher healthcare utilization and the cough can significantly impact a patient's career, can interfere with their work productivity and cause missed days from work.

I want to focus on the psychological burden of chronic cough, fear, anxiety, frustration, depression and even anger are common in patients. Patients who have baseline level of depression. This predicts that the cough can be more severe. Symptoms of depression, stress, and anxiety, of course, predict a worse quality of life, and importantly, improve if the cough gets better. I've taken care of cough patients for many years and what is universal in these patients is feelings of helplessness, embarrassment, and importantly, social isolation. They feel very isolated from family and friends because of an inability to control the cough. Patients also often comment about feeling dismissed by healthcare providers. Cough is viewed as a symptom and something that they can control, not a condition or disease.

Patients with chronic cough have more comorbidities than age match comparisons and cough can also coexist with conditions such as asthma and reflux. Reflux, rhinitis, and obesity are more common in patients with chronic cough, and these comorbidities of course also contribute to the burden of disease. Cough can persist for many years. It's not uncommon in my clinic for patients to have decades of coughing, and in fact, 20% of patients with chronic cough self-report that they've been coughing for 10 years or more.

This is largely a condition of older adults. It's more common in the fifth and six decades of life. Chronic cough is more prevalent in females. Studies report up to 70% of patients are female. Gender difference may be due to a heightened cough reflex in women. Females with chronic cough have a reduced health-related quality of life. Particularly women are more susceptible to the impact of cough when the cough lasts longer. Environmental and occupational factors can trigger cough and may play a role in chronic cough. The impact of occupation and environment is under-recognized and future studies are needed to further explore the role these irritants may play in the onset and persistence of chronic cough.

While the majority of patients are managed in primary care, many patients are referred to specialists. Pulmonary medicine is the most common referral. Other specialty referrals include ear, nose, and throat, allergy, and gastroenterology. As we said before, healthcare utilization is very high in patients with chronic cough. They often see specialists have multiple visits to providers. There can be a significant burden of testing and they often undergo test and procedures more than once. Patients also commonly report a history of multiple medication trials.

In summary, chronic cough is not just a symptom. It often becomes a condition or disorder and can have a significant impact on a patient's quality of life in all domains: physical, social, psychological, and economic. There's a tremendous need in the medical community to better evaluate and treat patients with chronic cough. Thank you for your attention.

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