NUR 520 Module 4 Milestone One Example

Milestone One: COPD Among Adults in Coös County, New Hampshire, as a Population Health Problem

[Student Name]

Southern New Hampshire University

NUR 520: Epidemiological and Biostatistical Applications in Healthcare

Milestone One

[Instructor Name]

[Date]

Milestone One: COPD Among Adults in Coös County, New Hampshire, as a Population Health Problem

A population health problem has to be described before it can be analyzed. This milestone describes chronic obstructive pulmonary disease among adults in Coös County, New Hampshire: who is affected, how many, how the county compares with the rest of the state and what conditions appear to drive the difference. The description shows that Coös has the state's highest estimated COPD prevalence under both crude and age-adjusted measures, that it also has the highest estimated smoking prevalence, and that barriers to care likely compound both, which together justify treating COPD in the county as a priority for nurse-led population health work.

The Population

Coös County is the northernmost and least populous county in New Hampshire, with an estimated total population of about 31,400 and about 26,300 adults aged 18 and older in the population base used by CDC's 2025 county estimates (Centers for Disease Control and Prevention [CDC], 2025). It is mostly rural, with small towns spread across mountains and forest, and its largest community grew around a paper mill that has since closed. Its residents skew older than New Hampshire as a whole, and age is one of the strongest predictors of COPD. The population of interest for this project is all adults living in the county, with particular attention to current and former smokers and to adults aged 65 and older.

Magnitude of the Problem

In the 2025 PLACES release, the crude estimate for diagnosed COPD among the county's adults is 9.5%, bounded by a 95% confidence interval of 7.7% to 11.4%. The age-adjusted estimate is 7.1% (5.9% to 8.5%). Both are the highest of New Hampshire's ten counties (CDC, 2025). Applied to about 26,300 adults, the crude estimate suggests roughly 2,500 adults living with diagnosed COPD, a figure calculated for this milestone. For context, weighting all ten counties by their adult populations gives a statewide figure near 6.2%, again computed for this milestone, and the national figure, standardized for age, held close to 6% across the decade from 2011, while remaining higher among adults aged 65 and older, rural residents and people who have ever smoked (Liu et al., 2023).

About the Estimates

Because the county is small, these figures are model-based estimates rather than direct counts. PLACES combines national survey responses with census data to estimate prevalence for every county, city and census tract, a design meant to give local health departments usable data regardless of population size (Greenlund et al., 2022). That design makes the Coös estimates possible, but it also means they should be read with their confidence intervals and described as estimates in every report. They count only adults who have been told by a health professional that they have COPD, so the true burden, including undiagnosed disease, is likely higher. These cautions do not weaken the problem description; they tell the reader how much weight each number can bear.

Determinants Suggested by the Data

The same data source shows several determinants that set Coös apart. Table 1 compares the county with the statewide average for selected measures.

Table 1

Selected PLACES Estimates for Coös County Compared With the New Hampshire County Average

Note. Coös values are from CDC PLACES, 2025 release. Statewide averages were calculated for this milestone by weighting the ten county estimates by adult population; they are not published CDC figures.

Interpreting the Determinants

Smoking is the most important determinant. Current smoking prevalence in Coös is about 40% higher than the statewide average, and smoking is the leading cause of COPD in the United States. The national trend data show COPD prevalence increasing among current and former smokers over the past decade (Liu et al., 2023), which makes cessation central to any response. The higher shares of adults reporting fair or poor health and disability suggest that many residents already live with chronic conditions that limit activity, consistent with a population in which COPD is advanced by the time it is diagnosed. Lack of insurance and transportation do not cause COPD, but they make diagnosis, cessation support and pulmonary rehabilitation harder to reach, and in a county where specialty care may be an hour or more away, those barriers can delay care until an exacerbation.

Problem Statement

Adults in Coös County have the highest estimated prevalence of diagnosed COPD and current smoking in New Hampshire, even after accounting for age, and they face greater barriers to insurance coverage and transportation than adults elsewhere in the state. Because these conditions compound one another, COPD in the county is likely to be diagnosed later, managed less consistently and accompanied by more disability than in other counties. This problem warrants population-level nursing interventions focused on cessation, earlier case finding in adults with symptoms and access to rehabilitation.

Significance for Nursing

Nurses are present at every point where this problem could be interrupted. Primary care nurses and care managers can deliver brief cessation counseling and follow up on referrals. Hospital and emergency nurses see exacerbations and can connect patients to rehabilitation and follow-up before discharge. Home health and public health nurses can reach people who cannot travel. For an MSN-prepared nurse in a leadership, education or population health role, the value of this description is that it shows where the burden is highest and which barriers are most likely to block care, which is the information needed to decide where nursing effort will make the most difference.

Questions for the Analysis Plan

The description raises questions that Milestone Two's analysis plan will need to address. How strong is the association between smoking and COPD, and how should it be measured? Are the differences between Coös and other counties larger than the uncertainty in the estimates? How much of the county's burden might be undiagnosed, given that the data count diagnosed disease only? And which outcomes, such as admissions for exacerbations or referrals to rehabilitation, could local clinical data provide to evaluate an intervention? These questions shape the statistical work in Modules 5 through 8.

Conclusion

COPD in Coös County is a well-defined population health problem: the highest estimated prevalence in the state, driven largely by smoking and compounded by barriers to care in a rural, older population. The data are model-based and describe diagnosed disease only, but they are consistent across measures and with national patterns. The next milestone will plan how to analyze the problem more precisely and how to measure the effect of a response.

References

Centers for Disease Control and Prevention. (2025). PLACES: County data (GIS friendly format), 2025 release [Data set]. https://data.cdc.gov/d/i46a-9kgh

Greenlund, K. J., Lu, H., Wang, Y., Matthews, K. A., LeClercq, J. M., Lee, B., & Carlson, S. A. (2022). PLACES: Local data for better health. Preventing Chronic Disease, 19, Article 210459. https://doi.org/10.5888/pcd19.210459

Liu, Y., Carlson, S. A., Watson, K. B., Xu, F., & Greenlund, K. J. (2023). Trends in the prevalence of chronic obstructive pulmonary disease among adults aged 18 years and older: United States, 2011-2021. Morbidity and Mortality Weekly Report, 72(46), 1250-1256. https://doi.org/10.15585/mmwr.mm7246a1