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Economic and Social Burden of COPD

Because COPD is highly prevalent and can be severely disabling, direct medical expenditures and the indirect costs of morbidity and premature mortality from COPD can represent a substantial economic and social burden for societies and public and private insurance payers worldwide. Nevertheless, very little quantitative information concerning the economic and social burden of COPD is available in the literature today.

Economic Burden

Cost of illness studies provide insight into the economic impact of a disease. Some countries attempt to separate economic burden into disease-attributable direct and indirect costs. The direct cost is the value of healthcare resources devoted to diagnosis and medical management of the disease. Indirect costs reflect the monetary consequences of disability, missed work and school, premature mortality, and caregiver or family costs resulting from the illness. Data on these topics from developing countries are not available, but data from the US and some European countries provide an understanding of the economic burden of COPD in developed countries.

United States. Figure 2-4 compares the estimated costs of various lung disorders in the US in 1993. In 1993, the annual economic burden of COPD in the US was estimated at $23.9 billion¹⁷, including $14.7 billion in direct expenditures for medical care services, $4.7 billion in indirect morbidity costs, and $4.5 billion in indirect costs related to premature mortality. With an estimated 15.7 million cases of COPD in the US³⁰, the estimated direct cost of COPD is $1,522 per COPD patient per year.

Figure 2.4

Direct and Indirect Costs of Lung Diseases, 1993 (US$ Billions)

In a US study³¹ of COPD-related illness costs based on the 1987 National Medical Expenditure Survey, per capita expenditures for inpatient hospitalizations of COPD patients ($5,409 per hospitalization) were 2.7 times the expenditures for patients without COPD ($2,001 per hospitalization). In 1992, under Medicare, the US government health insurance program for individuals over 65, annual per capita expenditures for people with COPD ($8,482) were nearly 2.5 times higher than annual expenditures for people without COPD ($3,511)³².

United Kingdom. In 1996, the direct cost of COPD in the UK was approximately £846 million (about US $1.393 billion) or £1,154 (about US $1,900) per person per year, according to data from the National Health Service (NHS) Executive33. Pharmaceutical expenditures for COPD and allied conditions accounted for 11.0% of the total expenditures for prescription medications Only 2% of total primary care expenditures were for COPD-related visits.

In 1996, lost work productivity, disability, and premature mortality from COPD in the UK accounted for an estimated 24 million days of work lost. The indirect cost of the disease was estimated at £600 million (about US $960 million) for attendance and disability living allowance and £1.5 billion (about US $2.4 billion) to employers for work absence and reduced productivity²⁴.

The Netherlands. In 1993, the direct cost of COPD in the Netherlands was estimated to exceed US $256 million, or US $813 per patient per year. Assuming constant costs and treatment patterns, the direct cost is expected to reach US $410 million per year by 2010. In 1993 inpatient hospitalizations accounted for 57% of the total direct cost of COPD, and medications accounted for an additional 23%. The indirect cost of COPD in the Netherlands was not available^34.

Sweden. The direct cost of COPD-related medical care in Sweden was estimated at 1.085 billion SEK (about US $179.4 million) in 1991. The estimated indirect cost of COPD was an additional 1.699 billion SEK (about US $280.8 million)³⁵.

Comparison of different countries. Figure 2-5 provides data on the economic burden of COPD in four countries with Western styles of medical practice and social or private insurance structures. The data are standardized to equivalent year on a per capita basis. After adjusting to a common base year and population, the costs of COPD were relatively similar. The remaining variability in across-country estimates of economic burden can be partly explained by several factors, including: disease prevalence and demographics, particularly smoking patterns; the type and usage patterns of healthcare and non-healthcare services among patients with COPD; the relative prices of healthcare services; employment and wage rates; and the availability of medical prevention strategies and treatments for COPD. Similar data from developing countries are not available.

Home care. Individuals with COPD frequently receive professional medical care in their homes. In some countries, national health insurance plans provide coverage for oxygen therapy, visiting nursing services, rehabilitation, and even mechanical ventilation in the home, although coverage for specific services varies from country to country³⁶.

Any estimate of direct medical expenditures for home care under-represents the true cost of home care to society, because it ignores the economic value of the care provided to those with COPD by family members. In developing countries especially, direct medical costs may be less important than the impact of COPD on workplace and home productivity. Because the healthcare sector might not provide long-term supportive care services for severely disabled individuals, COPD may force two individuals to leave the workplace - the affected individual and a family member who must now stay home to care for the disabled relative. Since human capital is often the most important national asset for developing countries, COPD may represent a serious threat to their economies.

Social Burden

Since mortality offers a limited perspective on the human burden of a disease, it is desirable to find other measures of disease burden that are consistent and measurable across nations. The World Bank/WHO Global Burden of Disease Study19 designed a method to estimate the fraction of mortality and disability attributable to major diseases and injuries using a composite measure of the burden of each health problem, the Disability-Adjusted Life Year (DALY). The DALYs for a specific condition are the sum of years lost because of premature mortality and years of life lived with disability, adjusted for the severity of disability.

The leading causes of DALYs lost worldwide in 1990 and 2020 (projected) are shown in Figure 2-6. In 1990, COPD was the twelfth leading cause of DALYs lost in the world, responsible for 2.1% of the total. According to the projections, COPD will be the fifth leading cause of DALYs lost worldwide in 2020, behind ischemic heart disease, major depression, traffic accidents, and cerebrovascular disease. This substantial increase in the global burden of COPD projected over the next twenty years reflects, in large part, the increasing use of tobacco worldwide and the changing age structure of populations in developing countries.

References

1.        Pride NB, Vermeire P, Allegra L. Diagnostic labels applied to model case histories of chronic airflow obstruction. Responses to a questionnaire in 11 North American and Western European countries. Eur Respir J 1989; 2:702-9.

2.        Mannino DM, Brown C, Giovino GA. Obstructive lung disease deaths in the United States from 1979 through 1993. An analysis using multiple-cause mortality data. Am J Respir Crit Care Med 1997; 156:814-8.

3.        Buist AS, Vollmer WM. Smoking and other risk factors. In: Murray JF, Nadel JA, eds. Textbook of respiratory medicine. Philadelphia: WB Saunders Co.; 1994. p. 1259-87.

4.        Thom TJ. International comparisons in COPD mortality. Am Rev Respir Dis 1989; 140:S27-34.

5.        Xu X, Weiss ST, Rijcken B, Schouten JP. Smoking, changes in smoking habits, and rate of decline in FEV1: new insight into gender differences. Eur Respir J 1994; 7:1056-61.

6.        Feinleib M, Rosenberg HM, Collins JG, Delozier JE, Pokras R, Chevarley FM. Trends in COPD morbidity and mortality in the United States. Am Rev Respir Dis 1989; 140:S9-18.

7.        Chen JC, Mannino MD. Worldwide epidemiology of chronic obstructive pulmonary disease. Current Opinion in Pulmonary Medicine 1999; 5:93-9.

8.        Dossing M, Khan J, al-Rabiah F. Risk factors for chronic obstructive lung disease in Saudi Arabia. Respiratory Med 1994; 88:519-22.

9.        Dennis R, Maldonado D, Norman S, Baena E, Martinez G. Woodsmoke exposure and risk for obstructive airways disease among women. Chest 1996; 109:115-9.

10.     Perez-Padilla R, Regalado U, Vedal S, Pare P, Chapela R, Sansores R, et al. Exposure to biomass smoke and chronic airway disease in Mexican women. Am J Respir Crit Care Med 1996; 154:701-6.

11.     Behera D, Jindal SK. Respiratory symptoms in Indian women using domestic cooking fuels. Chest 1991; 100:385-8.

12.     Amoli K. Bronchopulmonary disease in Iranian housewives chronically exposed to indoor smoke. Eur Respir J 1998; 11:659-63.

13.     Pandey MR. Prevalence of chronic bronchitis in a rural community of the Hill Region of Nepal. Thorax 1984; 39:331-6.

14.     Pandey MR. Domestic smoke pollution and chronic bronchitis in a rural community of the Hill Region of Nepal. Thorax 1984; 39:337-9.

15.     Samet JM, Marbury M, Spengler J. Health effects and sources of indoor air pollution. Am Rev Respir Dis 1987; 136:1486-508.

16.     National Center for Health Statistics. Current estimates from the National Health Interview Survey, United States, 1995. Washington, DC: Department of Health and Human Services, Public Health Service, Vital and Health Statistics; 1995. Publication No. 96-1527.

17.     National Heart, Lung, and Blood Institute. Morbidity & mortality: chartbook on cardiovascular, lung, and blood diseases. Bethesda, MD: US Department of Health and Human Services, Public Health Service, National Institutes of Health; 1998. Available from: URL: www.nhlbi.nih.gov/nhlbi/seiin/other/cht-book/htm

18.     Soriano JR, Maier WC, Egger P, Visick G, Thakrar B, Sykes J, et al. Recent trends in physician diagnosed COPD in women and men in the UK. Thorax 2000; 55:789-94.

19.     Murray CJL, Lopez AD. Evidence-based health policy - lessons from the Global Burden of Disease Study. Science 1996; 274:740-3.

20.     Murray CJL, Lopez AD, eds. The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries and risk factors in 1990 and projected to 2020. Cambridge, MA: Harvard University Press; 1996.

21.     Xian Sheng Chen. Analysis of basic data of the study on prevention and treatment of COPD. Chin J Tuber Respiratory Dis 1998; 21:749-52 (with English abstract).

22.     Higgins MW, Thom T. Incidence, prevalence, and mortality: intra- and inter-country differences. In: Hensley M, Saunders N, eds. Clinical epidemiology of chronic obstructive pulmonary disease. New York: Marcel Dekker.; 1989. p. 23-43.

23.     National Center for Health Statistics. National hospital interview survey. Vital and health statistics, series 10 (issues from 1974 to 1995).

24.     Calverley PMA. Chronic obstructive pulmonary disease: the key facts. London: British Lung Foundation; 1998.

25.     Office of National Statistics. Mortality statistics (revised) 1994, England and Wales. London: Her Majesty’s Stationery Office; 1996.

26.     World Health Organization. World health statistics annual 1995. Geneva: World Health Organization; 1995.

27.     World Health Organization, Geneva. Available from: URL: www.who.int

28.     Renzetti AD, McClement JH, Litt BD. The Veterans Administration Cooperative Study of Pulmonary Function. III: Mortality in relation to respiratory function in chronic obstructive pulmonary disease. Am J Med 1966; 41:115-29.

29.     Incalzi RA, Fuso L, De Rosa M, Forastiere F, Rapiti E, Nardecchia B, et al. Co-morbidity contributes to predict mortality of patients with chronic obstructive pulmonary disease. Eur Respir J1997; 10:2794-800.

30.     Singh GK, Matthews TJ, Clarke SC. Annual summary of births, marriages, divorces, and deaths: United States, 1994. Monthly Vital Statistics Report 14 (13). National Center for Health Statistics, Hyattsville, MD.

31.     Sullivan SD, Strassels S, Smith DH. Characterization of the incidence and cost of COPD in the US. Eur Respir J 1996; 9:S421.

32.     Grasso ME, Weller WE, Shaffer TJ, Diette GB, Anderson GF. Capitation, managed care, and chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1998; 158:133-8.

33.     National Health Service Executive. Burdens of disease: a discussion document. London: Department of Health; 1996.

34.     Rutten-van Molken MP, Postma MJ, Joore MA, Van Genugten ML, Leidl R, Jager JC. Current and future medical costs of asthma and chronic obstructive pulmonary disease in the Netherlands. Respir Med 1999; 93:779-87.

35.     Jacobson L, Hertzman P, Lofdahl C-G, Skoogh B-E, Lindgren B. The economic impact of asthma and COPD in Sweden 1980 and 1991. Respir Med 2000; 94:247-55.

36.     Fauroux B, Howard P, Muir JF. Home treatment for chronic respiratory insufficiency: the situation in Europe in 1992. The European Working Group on Home Treatment for Chronic Respiratory Insufficiency. Eur Respir J 1994; 7:1721-6.

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