Economic impact of pulmonary drugs on direct costs of stable chronic obstructive pulmonary disease

COPD patients' characteristics, usual care, and adherence to guidelines: the Greek UNLOCK study

Purpose

GOLD guidelines classify COPD patients into A–D groups based on health status as assessed by COPD Assessment Test (CAT) or mMRC tools and exacerbations and recommend single or dual long-acting bronchodilators as maintenance therapy, with additional inhaled corticosteroids (ICS) if the disease remains uncontrolled. We aimed to classify primary care COPD patients into A–D groups, assess usual treatment and adherence to guidelines, potential mismatches between CAT-and mMRC-based classification and described symptoms within groups.

Patients and methods

A total of 257 primary care COPD patients were enrolled between 2015 and 2016 in Greece. Physicians used structured interviews to collect cross-sectional data including demographics, symptoms, CAT, mMRC scores, and medications. Patients were classified into A–D groups based on CAT and mMRC, and prevalence of symptoms and medication was estimated within A–D groups. Interviews with physicians were also performed to explore additional issues about treatment and adherence to guidelines.

Results

Mean (SD) age was 65 (12.3) years with 79% males. The majority of patients reported uncontrolled symptoms (91% and 61% with ≥10 CAT or ≥2 mMRC scores, respectively). Thirty-seven percentage had $2 exacerbations in the past year. Group B was the largest followed by Groups D, A, and C. Patients were classified as more severe by CAT than by mMRC. In all groups, the majority were treated with combined long-acting beta agonist/ICS (> 50%). When patients were asked to report their main symptoms, dyspnea and cough were the most important symptoms mentioned, and there was a great variation between the A–D groups. However, Groups A–C reported mainly morning symptoms, whereas Group D suffered symptoms all day. Physicians reported a significant number of barriers to implementing guidelines, eg, frequent lack of guideline updates, access to diagnostic procedures, and prescription-reimbursement issues.

Conclusion

Our study confirms poor adherence to guidelines regarding treatment with an overuse of ICS and important barriers to implementation. A mismatch in classification occurs depending on the tool used, which can mislead clinicians in their choice of treatment.

Economic impact of chronic obstructive pulmonary disease: A cross-sectional study at teaching hospital in South India

Background

Chronic obstructive pulmonary disease continues to be the important contribution toward disability, death, and burden in the costs of health care globally. Economic impact of COPD is attributed with substantial direct and indirect costs. COPD affects the productivity of work that poses a burden on the employers and also on individuals in terms of loss of pay, limitation of activities, and related disability.

Materials and Methods

Hospital-based cross-sectional study among 24 respondents in selected hospital in Udupi Taluk. Respondents were identified by purposive sampling technique and data were collected in respondent's mother tongue. An interviewer administered questionnaire was used to collect data related to patient's demographic status, disease history, and direct and indirect costs of COPD. Data were analyzed using SPSS software version 15.

Results

The mean total direct medical cost that was observed among 24 respondents was Rs. 29,885 ± 11,995.33 and the mean total direct nonmedical cost was Rs. 7,441.25 ± 2,228.90. The mean total direct medical costs of COPD patients with comorbidity were Rs. 28,148.2353 ± 2,578.01580 and for those without comorbid illness was Rs. 13,460.0000 ± 1,255.33528. The observed mean absenteeism in the past 28 days was 193.50 ± 33.62 h. The mean absolute presenteeism of respondents is 72.05 ± 7.55.

Conclusions

The major drivers of the total cost were cost of hospitalizations and medication costs. Acknowledging the costs and economic impact of COPD is therefore extremely important in the management of COPD and in reducing the mortality and morbidity related to COPD and in improving adherence to treatment.

Social economic costs of COPD in Extremadura (Spain): an observational study

Purpose

COPD has been associated with a high number of comorbidities and a relatively high level of health care resource utilization. This study aimed to estimate the social economic impact of COPD in the autonomous community of Extremadura (Spain) in 2015.

Patients and methods

This is a retrospective observational study carried out using a representative sample of patients diagnosed with COPD in Extremadura. Sociodemographic data, data on health care resource utilization, formal and informal care received by the patients, and loss of labor productivity in the last 12 months were collected through an electronic data collection platform. Direct health care costs were estimated using the bottom-up approach, costs of informal care were assessed using the substitution method, and labor productivity losses were calculated using the human capital method.

Results

A sample of 386 patients was obtained (mean age: 71.8±10.3 years, males: 76.2%). The results show an average annual cost per patient of 3,077 euros. Direct health care costs represented 43.8% (1,645 euros), direct non-health care costs amounted to 38.3% (1,440 euros), and labor productivity losses represented 17.9% (672 euros) of the average annual cost. The total annual cost of patients with COPD in Extremadura reached 36.2 million euros in 2015.

Conclusion

COPD poses a significant burden for the health care system and the society of Extremadura. The implementation of preventive and control measures could result in a substantial reduction in the economic impact.

Annual direct medical costs of bronchiectasis treatment: Impact of severity, exacerbations, chronic bronchial colonization and chronic obstructive pulmonary disease coexistence

Patients with bronchiectasis (BE) present exacerbations that increase with severity of the disease. We aimed to determine the annual cost of BE treatment according to its severity, determined by FACED score, as well as the parameters associated with higher costs. Multicentre historical cohorts study with patients from six hospitals in Spain. The costs arising during the course of a year from maintenance treatment, exacerbations, emergency visits and hospital admissions were analysed. In total, 456 patients were included (56.4% mild BE, 26.8% moderate BE and 16.9% severe BE). The mean cost was €4671.9 per patient, which increased significantly with severity. In mild BE, most of the costs were due to bronchodilators and inhaled steroids; in severe BE, most were due to exacerbations and inhaled antibiotics. Forced expiratory volume in 1 second (FEV₁%), age, colonization by Pseudomonas aeruginosa and the number of admissions were independently related to higher costs. The highest costs were found in patients with BE associated with chronic obstructive pulmonary disease, with the most exacerbations and with chronic bronchial colonization by Pseudomonas aeruginosa (PA). In conclusion, BE patients gave rise to high annual costs, and these were doubled on each advance in severity on the FACED score. FEV₁%, age, colonization by PA and the number of admissions were independently related to higher costs.

Hospitalization Due to Co-Morbid Conditions is the Main Cost Driver Among Subjects With COPD-A Report From the Population-Based OLIN COPD Study

BACKGROUND

Co-morbidities are common in COPD; however, there is a lack of population-based studies evaluating the health economic impact of co-morbid diseases for subjects with COPD. The main objective of this study was to estimate annual direct health-care costs, divided into costs due to non-respiratory and respiratory conditions, comparing subjects with and without COPD.

METHODS

Subjects with and without COPD derived from population-based cohorts in northern Sweden have been invited to annual examinations involving spirometry and structured interviews since 2005. This paper is based on data from 1472 subjects examined in 2006. COPD classification was based on spirometry.

RESULTS

Mean annual costs for both respiratory and non-respiratory conditions were significantly higher for subjects with COPD than non-COPD subjects, in total USD 2139 vs. USD 1276 (p = 0.026), and COPD remained significantly associated with higher costs also after adjustment for common confounders as age, smoking habits, BMI and sex. The mean total cost increased with COPD disease severity and was higher for all severity stages (GOLD) than for non-COPD subjects. Hospitalization due to non-respiratory diseases was the main cost driver in COPD, after adjustment for common confounders amounting to about 46% (unadjusted 62%) of the total COPD-costs.

CONCLUSIONS

Costs were higher for COPD than non-COPD. In COPD, costs for co-morbid conditions were higher than those for respiratory conditions, and hospitalization due to co-morbid conditions was the main cost driver also when adjusted for common confounders.

Treatment patterns, resource use and costs of idiopathic pulmonary fibrosis in Spain--results of a Delphi Panel

Background

Idiopathic pulmonary fibrosis (IPF) is a form of chronic fibrosing interstitial pneumonia characterized by progressive worsening of dyspnea and lung function, with a poor prognosis. The objective of this study was to determine treatment patterns, resource use and costs of managing Spanish patients with IPF.

Methods

A three-round Delphi consensus panel of 15 clinical experts was held between December 2012 and June 2013 using questionnaires to describe the management of patients with IPF. A cost analysis based on Delphi panel estimates was made from the Spanish National Health System (NHS) perspective, including the direct costs of IPF diagnosis and management. Unit costs were applied to Delphi panel estimates of health resource use. Univariate sensitivity analyses were made to evaluate uncertainties in parameters.

Results

The Delphi panel estimated that 20, 60 and 20 % of IPF patients presented with stable disease, slow and rapid disease progression, respectively. The estimated annual cost per patient with stable disease, slow and rapid disease progression was €11,484, €20,978 and €57,759, respectively. This corresponds to a weighted average annual cost of €26,435 with itemized costs of €1,184 (4.5), €7,147 (27.0), €5,950 (22.5), €11,666 (44.1) and €488 (1.9 %) for the diagnosis of IPF, treatment, monitoring, management of acute exacerbations and end-of-life care, respectively. The parameter that varied the annual cost per patient the most was resource use associated with acute exacerbations.

Conclusions

The management of patients with IPF in Spain, especially patients with rapid disease progression, has a high economic impact on the NHS.

Electronic supplementary material

The online version of this article (doi:10.1186/s12890-016-0168-6) contains supplementary material, which is available to authorized users.

Adherence to Current COPD Guidelines in Turkey

INTRODUCTION-OBJECTIVE: Despite the availability of national and international guidelines, chronic obstructive pulmonary diseases (COPD) treatment is not always prescribed according to these recommendations. We aimed to see if COPD patients in Turkey have been treated appropriately according to COPD guidelines.

METHODS

This is a cross-sectional study carried out in six different chest diseases clinics. The COPD outpatients were categorized by spirometry classification (SC) and the combined classification (CC) of COPD. The treatment protocols were evaluated to check whether they were suitable for both classifications.

RESULTS

Overall, 307 patients were included in the study. Of the treatment protocols, 40.4% were suitable for both classifications: 30.9% for CC and 20.8% for SC. A total of 51.8% of the patients were reported to be using an unsuitable therapy for SC and 38.4% for CC. Ninety-eight per cent of the unsuitable treatment was overtreatment. Fifty-eight per cent of the patients were using LABA + LAMA + ICS. Improper ICS usage was identified in 97.1% in CC, 93.1% in SC. The cost savings of all patients in one year would be 17,099$ with an appropriate treatment protocol following COPD guidelines.

CONCLUSION

The most common type of inappropriate COPD treatments is overtreatment, generally with ICS. As treatment protocols following COPD guidelines change over time, there is still a low rate of adherence by clinicians in their clinical practice to guideline recommendations. Awareness of these guidelines by pulmonary specialists should be improved.

Economic valuation and determinants of informal care to disabled people with Chronic Obstructive Pulmonary Disease (COPD)

Background

We aimed to estimate the monetary value of informal care of disabled people with chronic obstructive pulmonary disease (COPD) in Spain and to identify the main determinants of the time involved in informal caregiving.

Methods

We used the Survey on Disabilities, Autonomy and Dependency carried out in Spain in 2008 to obtain information on disabled individuals with COPD and their informal caregivers. Assessment of informal caregiving time was performed using the proxy good method. A statistical multivariate analysis (ordered probit model) was performed to study the determinants of informal care provided.

Results

It was estimated that 220,892 disabled people with COPD received informal care. The total annual number of caregiving hours was 694.44 million, with an estimated monetary value between 4,981 and 8,254 million EUR. Based on the condition of having received informal care, the cost of informal care per disabled person with COPD ranged from 24,549 to 40,681 EUR per year (depending on the shadow price applied). This value varies significantly depending on the degree of dependency; it ranged from 17,089 EUR per person annually for non-dependents to 33,033 EUR for those who were greatly dependent (under the most conservative scenario). Degree of dependency and the formal care received were the main variables that explained the variability of informal caregiving time provided.

Conclusions

The results partially reveal the high hidden social costs, and the association between the level of dependency and the time provided by the caregivers. This information should be a useful tool to design policies that focus on improving caregivers’ well-being.

Costs of chronic obstructive pulmonary disease in relation to compliance with guidelines: a study in the primary care setting

BACKGROUND

The aim of this study was to analyse the economic impact of nonadherence to the Global Initiative for Obstructive Lung Disease (GOLD) guidelines in patients with chronic obstructive pulmonary disease (COPD).

METHODS

A retrospective analysis was carried out on a claim database. Patients aged at least 40 years with a diagnosis of COPD were eligible for this analysis. Demographics, medical data and use of resources were collected and direct and indirect costs were analysed (from January 2008 to June 2009). A probabilistic multivariate sensitivity analysis of avoided costs was carried out. All results are presented in annualized form and costs are expressed in Euros (2009).

RESULTS

A total of 1365 patients were included, 79.5% were men. The mean age (±standard deviation) was 71.4 (±10.3) years, the mean forced expiratory volume in 1 s (FEV1) was 65.3% and they had a COPD history of 5.5 (±2.9) years. Patients were divided into an adherent group and a nonadherent group depending on whether therapeutic recommendations according to severity defined in the GOLD guidelines (2007) were followed. Patients in both groups were also classified as having stage II (FEV1 < 80% and < 50%) or stage III disease (FEV1 < 50% and ≥ 30%). The total annual drug cost per patient in the nonadherent group was €771.5 while it was only €426.4 for the adherent group. The average direct cost per patient per year in the nonadherent stage II group was €1465 (±971) and it rose to €2942 (±1918) for patients in the nonadherent group with stage III disease. The potential saving from the implementation of the GOLD guidelines in stage II COPD amounted to €758 per patient per year (68% saving on drug cost). In contrast, the cost for patients with stage III disease was higher in the adherent group versus the nonadherent group (€2468).

CONCLUSIONS

The cost of COPD may vary according to compliance with the GOLD guidelines. The cost observed for patients with stage II disease is higher than expected in patients who adhere to treatment, but patients with stage III disease treated according to the GOLD guidelines had significantly higher treatment costs.

Evaluation of pharmacotherapy of obstructive airway diseases in the Montenegrin outpatient care: comparison with two Scandinavian countries

BACKGROUND

This study is aimed at evaluating the pharmacotherapy of obstructive airway diseases (OAD) in the Montenegrin outpatient care (MOC) in 2010.

METHODS

Data on the reimbursed drugs which were prescribed during the reference period were obtained from the National Database that was established within the Health Insurance Fund of Montenegro in 2004. We have applied the standard pharmacoepidemiologic methodology with the defined daily dose (DDD) along with the Anatomical Therapeutic Chemical (ATC) classification of drugs. Clinical entities of OAD were classified according to the International Classification of Diseases (ICD-Revision X).

RESULTS

Prescribing and the subsequent use of drugs for OAD (ATC code R03) in 2010 was 18.18 DDD/1000inhabitants/day, much lower than in some developed countries. Fenoterol/ipratropium and salmeterol/fluticasone fixed combinations had the highest utilisation level, accounting for more than 50% of all OAD drugs. About 90% of OAD drugs were prescribed for COPD and asthma.

CONCLUSIONS

Obtained results indicate that there are still large differences in OAD drug utilisation in MOC when compared with developed countries, but also some improvement in pharmacological approach to the pharmacotherapy of OAD in comparison to the earlier period.

Adherence to current guidelines for chronic obstructive pulmonary disease (COPD) among patients treated with combination of long-acting bronchodilators or inhaled corticosteroids

Background

To estimate the potential cost savings by following the current Global Initiative for Chronic Obstructive Lung Disease (GOLD) guideline recommendations in patients being treated for chronic obstructive pulmonary disease (COPD) with the combination of long-acting β₂-agonist (LABA), long-acting muscarinic antagonist (LAMA) or inhaled corticosteroids (ICS).

Methods

The Geisinger Health System (GHS) database was utilized to identify subjects between January 1, 2004 to March 12, 2007. The index date was based on the first prescription of a LAMA plus LABA, LAMA plus LABA/ICS, or LABA plus ICS. Patients were included in the study if they: had a COPD diagnosis; had data representative of treatment 12 months prior to and 12 months post index date; were 40 years of age or over; had no prior diagnosis for asthma; and had pulmonary function test (PFT) data. We examined the baseline characteristics of these patients along with their healthcare resource utilization. Based on PFT data within 30 days of the index date, a subgroup was classified as adhering or non-adhering to GOLD guidelines.

Results

A total of 364 subjects could be classified as adhering or non-adherent to current GOLD guidelines based on their PFT results. The adherent subgroup received COPD medications consistent with current GOLD guidelines. Of the LAMA plus LABA cohort, 25 patients adhered and 39 patients were non-adherent to current GOLD guidelines. In the cohort of LABA plus ICS, 74 patients were adherent and 180 patients non-adherent to current GOLD guidelines. In the cohort of LAMA plus LABA/ICS, 21 patients were adherent and 25 patients non-adherent to current GOLD guidelines. GOLD adherence was associated with mean total cost of all services savings of $5,889 for LAMA plus LABA, $3,330 for LABA + ICS, and $10,217 for LAMA plus LABA/ICS cohorts.

Conclusion

Staging of COPD with a PFT and adherence to current GOLD guidelines was associated with lower costs in subjects with moderate to severe COPD. Appropriate use of LAMA plus LABA, LABA plus ICS, and LAMA plus LABA/ICS has economic as well as clinical benefits for patients and payers.

The excessive use of inhaled corticosteroids in chronic obstructive pulmonary disease

Despite the fact that the recommendations of the main clinical guidelines have restricted the indications for inhaled corticosteroids in chronic obstructive pulmonary disease (COPD), currently more than 80% of patients are receiving this treatment in Spain, mostly with high doses. A detailed review of the literature does not justify the use of these high doses, a position that agrees with the recommendations of the FDA. A re-evaluation of their safety, the consistency of the data on their efficacy showing similar results with moderate doses and a better patient selection require the use of this treatment in COPD patients to be reconsidered.

Inappropriate overuse of inhaled corticosteroids for COPD patients: impact on health costs and health status

The aim of this study was to evaluate the relationship between inappropriate overuse of inhaled corticosteroids and self-reported health status and the annual cost of patients with stable chronic obstructive pulmonary disease (COPD) recruited in the primary-care setting. An observational, crossover, descriptive study was conducted. Patients with stable COPD and aged ≥40 years, evaluated in primary care, were included. Data collected were demographic variables, clinical characteristics, self-reported health status (SF-12), the severity of the illness, treatment, and health-care resource utilization in the past year. The patients were recruited during a period of 3 months (from January 1 to March 31, 2003). Use was considered inappropriate when corticosteroids were prescribed by physicians for patients not meeting criteria for its use as recommended in guidelines. A total of 10,711 patients [75.6% males; mean age = 67.1 (SD = 9.66) years] were evaluated. Disease severity was mild in 35.5% of the cases, moderate in 53.4%, and severe in 11.2%. Among them, 3,697 (34.5%) subjects were prescribed inhaled corticosteroids or drug combinations containing such therapies, with a rate of inappropriate use of 18.2%. Physical health status was significantly lower among patients showing inappropriate corticosteroids use: 37.35 (SD = 9.53) vs. 40.7 (SD = 9.80) (p < 0.05). The annual cost per patient of COPD management was significantly higher in the group with inappropriate inhaled corticosteroids use: <euro>1,590 (SD = 1,834) vs. <euro>1,157 (SD = 1,536) (p < 0.05). Factors statistically associated with inappropriate use of corticosteroids were educational attainment [OR: 2.77 (95% CI: 1.36-5.63) for nonuniversity training], a history of heart disease [OR: 1.42 (95% CI: 1.02-1.97)], depression [OR: 1.47 (95% CI: 1.05-2.05)], any allergy [OR 1.69 (95% CI: 1.13-2.54)], and physical health status [OR 0.97 (95% CI: 0.96-0.98)]. Lack of adherence to the recommended criteria for using inhaled corticosteroids therapy in the management of COPD patients was associated with lower self-reported health status and higher costs. Factors statistically associated with inappropriate use of corticosteroids were educational attainment, a history of heart disease, depression, any allergy, and physical health status.

[Causes of mortality in COPD]

Chronic obstructive pulmonary disease (COPD) is one of the main causes of death in Spain and elsewhere in the world, with an estimated 18,000 and 2.75 million deaths annually. Mortality is predicted to increase in the next few years due to smoking and the aging population. Multiple studies confirm that COPD is underreported as a cause of death on death certificates, due to the difficulty of determining the final cause of death in these patients. The main causes of mortality in COPD range from lung cancer and cardiovascular disease in patients with mild COPD to respiratory failure in the most advanced stages. Fortunately, in the latest updates, guidelines for the management and treatment of the disease identify reduction of mortality as one of the main clinical objectives to be achieved in these patients.

Excessive costs of COPD in ever-smokers. A longitudinal community study

AIM

We aimed to estimate the societal treatment-related costs of COPD in hospital- and population-based subjects with spirometry defined COPD, relative to a control group.

METHODS

81 COPD cases and 132 controls without COPD were randomly recruited from a general population, as were 205 COPD patients from a hospital register. All participants were ever-smokers of at least 40 years of age, followed for 12 months. Data on comorbid conditions and spirometry were collected at baseline. Standardized telephone interviews every third month gave information on use of healthcare services and exacerbations of respiratory symptoms.

RESULTS

The increased (excessive) median annual costs per case having stage II, stage III and stage IV COPD were € (95% CI) 400 (105-695), 1918 (1268-2569) and 1870 (1031-2709), respectively, compared to the population-based controls. Costs increased with €81 (95% CI 50-112) per exacerbation of respiratory symptoms and €461 (95% CI 354-567) per comorbid condition. Excessive costs for hospital COPD patients were threefold that of the population-based COPD cases.

CONCLUSION

The excessive treatment-related cost of COPD stage II+ in ever-smokers of at least 40 years was estimated to €105 million for Norway. Comorbidity was a dominant predictor of excessive cost in COPD.

Misdiagnosis of patients receiving inhaled therapies in primary care

Aim:

To analyze the accuracy of diagnosis in a population receiving inhaled therapies due to respiratory diseases in a primary care setting.

Method:

Noninterventional, multicenter, cross-sectional, observational epidemiologic study methodology.

Results:

A total of 9752 subjects were evaluated. Of these, 4188 (42.9%) patients were diagnosed with asthma, 4175 (42.8%) with chronic obstructive pulmonary disease (COPD), and 1389 had a diagnosis of disease of unknown origin. Of those over the age of 40 years, 4079 (50.9%) had COPD and 2877 (35.9%) had asthma. Sixty percent of the subjects were men, and the proportion of men was higher in patients with COPD (83.2%) than in the group with asthma (39.8%, P < 0.0001). Of subjects with COPD, 17.3% had mild, 55.3% had moderate, 24.1% had severe, and 3.2% had very severe disease. With regard to the level of severity of asthma, 34.9% of subjects had intermittent, 34.6% had mild persistent, 27.1% had moderate persistent, and 3.5% had severe persistent disease. Only 13.9% of patients in the COPD group had all the characteristics of COPD based on the Global Initiative for Chronic Obstructive Lung Disease criteria and an absence of the characteristics of asthma.

Conclusions:

The majority of patients receiving inhaled therapy in primary care did not have an accurate diagnosis according to current international guidelines for COPD and asthma. More initiatives for improving diagnostic accuracy in respiratory diseases must be implemented in primary care.

Economics of COPD: literature review and experiences from field work

INTRODUCTION

The burden of diseases should be described in terms of costs. The available literature gives imprecise estimates of costs of chronic obstructive pulmonary disease (COPD) in the Nordic populations. Previous studies have methodological weaknesses related to choice of disease criteria, the use of highly selected populations and insufficient specification of the cost process. There are no robust estimates concerning the economics of COPD in Norway.

METHODS

We have conducted a 1 year follow-up cost of illness study in a general population, recruiting ever-smoking Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage 2+ COPD patients and ever-smokers without COPD. We have used diaries to recollect data, and comprehensive questionnaires to cover all costs of COPD.

RESULTS

The main challenges were the participants' unwillingness to complete diaries, the large amount of information and the logistics related to following up 476 individuals on four occasions during one year.

CONCLUSIONS

We doubt the effect of diaries. However, we recommend a detailed planning of logistics and to emphasize main cost drivers.

Determinants and predictors of the cost of COPD in primary care: a Spanish perspective

Objectives

1) To estimate the annual cost of patients with stable chronic obstructive pulmonary disease (COPD) followed in primary care in Spain; 2) To analyze the possible cost predictor variables.

Patients and methods

A multicenter, epidemiological, observational, descriptive study. Sociodemographic data, severity of disease, associated comorbidity, treatment followed by patients, quality of life (SF-12 questionnaire), health care resource utilization in the previous 12 months and duration of working disability due to COPD were collected.

Results

A total of 10,711 patients (75.6% men; 24.4% women) with a mean age of 67.1 ± 9.66 years were evaluated. The mean forced expiratory volume in one second (FEV₁) value was 57.4 ± 13.4%. The total cost per patient per year was €1,922.60 ± 2,306.44. The largest component of this cost was hospitalization (€788.72 ± 1,766.65), followed by cost of drugs (€492.87 ± 412.15) and visits to emergency rooms (€134.32 ± 195.44). Linear regression analysis found associated heart disease, FEV₁, physical component of quality of life, number of medical visits (primary care physician, pneumologist and emergency room), hospital admissions (frequency and duration of stay) and duration of working disability to be significant predictors of the total annual cost.

Conclusions

The total annual cost of a COPD patient followed in primary care in Spain was considered high in this study. The presence of associated heart disease, severity of airflow obstruction, physical component of quality of life, health care resource utilization and duration of work disability were found to be predictor of cost.

Study of the burden on patients with chronic obstructive pulmonary disease

BACKGROUND

Health-related quality of life measures are widely used in patients with chronic obstructive pulmonary disease (COPD). However, they are extremely limited when used to evaluate patients outside the clinical trials. The aim of this study was to analyse the burden of the disease using a simple, validated, self-administered questionnaire specifically developed for patients in daily clinical practice.

METHODS

A total of 3935 patients (74.5% men; mean age, 67 years) participated in a cross-sectional study. The burden of COPD on patients was measured using the Clinical COPD Questionnaire (CCQ). COPD was rated at four levels by the forced expiratory volume in one second (FEV(1)) according to The Global Initiative for Chronic Obstructive Lung Disease (GOLD) scale.

RESULTS

The disease mainly affects old men (more than 50% were over 65 years of age) and non-employed men (23% were employed). Of the patients studied, 22.7% continued smoking, especially men (24.4% of men vs. 18.1% of women). Most patients (54%) were diagnosed with moderate stage II COPD. Severity of COPD was lower in women: 29.6% of men had severe COPD compared with 13.7% of women. During the last year, 65.1% had at least one acute exacerbation and 36.6% were admitted to hospital because of COPD exacerbation. No association was found between the body mass index and COPD stage. The variable that most influenced the disease burden was dyspnoea, as progression from grade 0 to grade 4 increased the disease burden by 1.78 points for symptoms, 2.43 for functional state and 1.53 for mental state. The functional classification of COPD also had a significant influence on the disease burden.

CONCLUSIONS

The present findings show that dyspnoea and the degree of airflow limitation are the clinical variables that most affect the burden of COPD from the patient's point of view.

[Calculation of morbidity, use of resources and costs of patients treated with tiotropium bromide for COPD in a Spanish population]

OBJECTIVE

To determine the co-morbidity and economic impact of treatment with tiotropium bromide (TB) for COPD, in a population cared for by Spanish primary care teams (PCTs) and specialist physicians, in the context of routine clinical practice.

DESIGN

Retrospective multi-centre study.

SETTING

Four PCTs and 2 urban hospitals.

PARTICIPANTS

Patients with COPD receiving regular treatment with TB, during 2004.

MAIN MEASUREMENTS

Age and sex, episodes of co-morbidity, clinical parameters, resource use, and pharmacological groups. The costs model was established by differentiating semi-fixed from variable costs (pharmacy, tests, referrals) in the PCTs, as well as the visits, emergencies and hospital admissions occurring in the hospitals. A logistical regression analysis was made to correct the model. The costs were contrasted by analysis of covariance (ANCOVA), with the estimation of marginal means (Bonferroni adjustment).

RESULTS

Of 900 patients with COPD, 14.3% (n=129) received treatment with TB (95% CI, 12.0%-16.6%). The mean episodes/patient/year was 2.1 (1.4) versus 1.8 (1.3) (NS), seriousness/severity 41.3% versus 26.3% (P =.001), defined daily dose (DDD) 5928.5 (9624.1) versus 6187.7 (12471.3) (NS) and number visits/patient/year 15.1 (9.4) versus 17.3(11.9) (P=.044). After adjustments for age and sex, TB use was associated with Diabetes Mellitus (OR=1.6; 95% CI, 1.0-2.5; P=.034) and severity of patients' illness (OR=1.8; 95% CI, 1.2-2.8; P=.004). Quantification of unit cost/year was 2793.16 (3166.30) euros (3359.27 [3423.25] euros versus 2703.09 [3113.75] euros; P=.001). The adjusted patient cost/year was 2831.23 euros (SE, 217.32) with TB versus 2786.86 euros (SE, 88.53) without TB (NS).

CONCLUSIONS

TB is associated, as therapy complementing routine treatment, with the presence of Diabetes, and with the severity of the disease. The costs of COPD entail high resource consumption. The prescription of TB does not imply greater overall cost of the disease.

Clinical Efficacy of Moxifloxacin in the Treatment of Exacerbations of Chronic Bronchitis: A Systematic Review and Meta-Analysis

OBJECTIVE

As the research undertaken to date on the efficacy of the new antibiotics in the treatment of exacerbations of chronic bronchitis has taken the form of trials designed to demonstrate equivalence, we have no data on the advantages associated with the use of these new drugs with greater bactericidal activity. Our objective was to compare the clinical efficacy of moxifloxacin to that of the antibiotic regimens routinely used to treat such exacerbations by a systematic review of the literature and a meta-analysis.

METHODS

A manual and electronic search was performed to identify all clinical trials carried out between January 1997 and July 2005 to compare moxifloxacin and the antibiotics that are currently the first line treatment for exacerbations of chronic bronchitis. Once it had been established that the designs of the trials included were acceptable, a meta-analysis of clinical outcomes was performed.

RESULTS

Of the 45 studies identified, 9 met the inclusion criteria. Of these, 5 were double-blind randomized trials and 4 were randomized open trials. The 9 trials comprised a total of 3905 patients. The aggregate standardized mean difference in clinical success rate was 1.5% (95% confidence interval, -0.4 to 3.4%). Bacterial eradication rates ranged from 68.4% to 96% for the standard regimens, and from 87.7% to 96% for moxifloxacin. No intergroup differences in the percentages of patients lost to follow-up were observed in any of the studies.

CONCLUSIONS

Although the trials reviewed were designed to demonstrate equivalence, meta-analysis revealed that the clinical success rate achieved with moxifloxacin tended to be higher than that obtained in the groups that received standard antibiotic treatment.

[Attitudes toward the diagnosis of chronic obstructive pulmonary disease in primary care]

OBJECTIVE

Although the prevalence of chronic obstructive pulmonary disease (COPD) has increased among women, it is still considered a disease that mainly affects men. This study aimed to identify the diagnostic attitudes of primary care physicians toward patients with COPD according to gender and spirometric results.

METHODS

A representative sample of 839 primary care physicians participated in the study. Each physician dealt with 1 of 8 hypothetical cases based on a patient diagnosed with COPD. In half the cases, the physician was told the patient was a man. The other half of the physicians were told the same patient was a woman. After presentation of the medical history and results of physical examination, the physicians were asked to state a probable diagnosis and indicate the diagnostic tests that were necessary. They were then told the results of spirometry, which indicated obstruction ranging from moderate to severe. Negative results of bronchodilator tests and oral corticosteroid tests were then communicated.

RESULTS

COPD was more likely to be the preliminary diagnosis for male patients than for females (odds ratio [OR], 1.55; 95% confidence interval [CI], 1.15-2.1). This gender bias disappeared once the physicians were shown the abnormal results of spirometry. Patients with severe obstruction were more likely to be diagnosed with COPD than those with moderate obstruction (OR, 1.5; 95% CI, 1.08-2.09).

CONCLUSIONS

There is gender bias in the diagnosis of COPD. Patients with moderate obstruction are often believed not to have COPD. These biases may compromise the early diagnosis of the disease in a group of patients with ever increasing risk.