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      Medical Expenditures Attributed to Asthma and Chronic Obstructive Pulmonary Disease Among Workers — United States, 2011–2015

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          Abstract

          Asthma and chronic obstructive pulmonary disease (COPD) are respiratory conditions associated with a significant economic cost among U.S. adults ( 1 , 2 ), and up to 44% of asthma and 50% of COPD cases among adults are associated with workplace exposures ( 3 ). CDC analyzed 2011–2015 Medical Expenditure Panel Survey (MEPS) data to determine the medical expenditures attributed to treatment of asthma and COPD among U.S. workers aged ≥18 years who were employed at any time during the survey year. During 2011–2015, among the estimated 166 million U.S. workers, 8 million had at least one asthma-related medical event,* and 7 million had at least one COPD-related medical event. The annualized total medical expenditures, in 2017 dollars, were $7 billion for asthma and $5 billion for COPD. Private health insurance paid for 61% of expenditures attributable to treatment of asthma and 59% related to COPD. By type of medical event, the highest annualized per-person asthma- and COPD-related expenditures were for inpatient visits: $8,238 for asthma and $27,597 for COPD. By industry group, the highest annualized per-person expenditures ($1,279 for asthma and $1,819 for COPD) were among workers in public administration. Early identification and reduction of risk factors, including workplace exposures, and implementation of proven interventions are needed to reduce the adverse health and economic impacts of asthma and COPD among workers. MEPS is an annual household survey administered to a nationally representative sample of the noninstitutionalized civilian U.S. population through an in-person interview. † During the study period, 2011–2015, the years with the most recent available data, the annual survey response rates ranged from 54.9% in 2011 to 47.7% in 2015. To improve the precision and reliability of estimates, 2011–2015 data were combined. Participants’ self-reported information on medical conditions, the associated medical events, payments, source of payments, and employment status were collected during the MEPS interview. MEPS professional coders assigned a code to the medical condition or conditions associated with each medical event reported by the participant, using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Each medical event could be assigned one or more ICD-9-CM codes. Medical events associated with treated asthma were identified using ICD-9-CM code 493 and medical events associated with treated COPD were identified using ICD-9-CM codes 490, 491, 492, and 496. § Expenditures were calculated from the sum of payments from Medicaid, Medicare, private insurance, out-of-pocket expenses, and other sources ¶ for each treated asthma- and COPD-associated medical event. The annualized, total and per-person unadjusted medical expenditures for workers with asthma and COPD were estimated by type of medical event and source of payments. Workers were those who were “currently employed,” “had no job at the interview date but had a job to return to” or were employed at any time during the survey year. Information on participants’ current industry was categorized into 15 industry groups.** Data were weighted to produce nationally representative estimates using sample weights adjusted for the 5-year data. Data were analyzed using SAS software (version 9.4; SAS Institute) to account for the complex survey design. Estimates with relative standard error (standard error of the estimate divided by the estimate) ≥30% are not reported. All expenditure values were expressed in 2017 U.S. dollars using the Medical Care Consumer Price Index. †† During 2011–2015, among the annual average estimated 166 million U.S. persons aged ≥18 years who were working at any time during the survey year, 8 million (5%) workers had at least one asthma-related medical event, and 7 million (4%) had at least one COPD-related medical event, which accounted for 21 million asthma-associated and 15 million COPD-related medical events (Table 1). The proportion of current smokers among workers who had an asthma event during the study period was 13%; 24% had a COPD event. Annualized average per-person medical expenditures attributable to treated asthma and COPD were $901 and $681, respectively. Highest annualized expenditures per person attributable to treated asthma and treated COPD were among non-Hispanic whites ($923 and $742, respectively), persons with health insurance ($914 and $705, respectively), and current nonsmokers ($936 and $692, respectively). By age group, annualized per-person expenditures for asthma and COPD were highest among persons aged 45–64 years ($1,081) ≥65 years ($1,090), respectively. TABLE 1 Estimated number of workers with an asthma-related or chronic obstructive pulmonary disease–related medical event and annualized total and per-person expenditures,* by selected characteristics among workers aged ≥18 years — Medical Expenditure Panel Survey, United States, 2011–2015 Characteristic† No. of workers (x1,000) Asthma Chronic obstructive pulmonary disease No. of workers with an event (x1,000) Total expenditures ($) in millions Average expenditure ($) per person No. of workers with an event (x1,000) Total expenditures ($) in millions Average expenditure ($) per person Total 166,347 7,920 7,137 901 7,371 5,021 681 Age group (yrs) 18–34 21,704 1,012 626 619 499 93 186 35–44 70,773 2,961 2,268 766 2,421 515 213 45–64 63,467 3,375 3,648 1,081 3,568 3,355 940 ≥65 10,403 659 595 903 971 1,058 1,090 Sex Men 86,749 2,954 2,473 837 3,057 2,238 732 Women 79,598 5,053 4,663 923 4,403 2,783 632 Race/Ethnicity Hispanic 26,499 891 745 836 594 129 217 White, non-Hispanic 107,676 5,564 5,140 923 5,865 4,350 742 Black, non-Hispanic 18,712 1,037 879 847 613 375 611 Other 13,460 515 372 722 388 168 433 Household income <$35,000 39,521 1,794 1,520 847 1,810 1,091 603 $35,000–$74,999 53,373 2,486 2,112 850 2,579 2,113 819 ≥$75,000 73,375 3,726 3,505 940 3,070 1,817 592 Education Less than high school 67,266 2,396 2,185 911 2,961 2,838 959 High school or more 98,269 5,607 4,951 883 4,468 2,170 486 Insurance coverage Yes 142,396 7,509 6,866 914 6,916 4,875 705 No 23,951 498 270 542 544 146 268 U.S. Census region § Northeast 29,696 1,851 1,787 965 1,281 984 768 Midwest 36,660 1,757 1,621 923 1,941 1,757 905 South 60,870 2,683 2,381 887 2,826 1,117 395 West 38,809 1,714 1,348 787 1,408 1,162 825 Current smoking status ¶ Smoker 24,820 955 664 695 1,636 1,024 626 Nonsmoker 125,570 6,514 6,097 936 5,220 3,612 692 * All medical expenditures expressed in 2017 U.S. dollars. † Missing information on education for 812,000; on household income for 78,000; on region for 312,000; and on smoking status for 15,957,000 workers. Columns do not sum to totals because of rounding; those with missing values were excluded from the analysis. § https://www2.census.gov/geo/pdfs/maps-data/maps/reference/us_regdiv.pdf. ¶ Based on yes/no responses to the question “Do you currently smoke?” Prescription medication accounted for the highest number of events for asthma (15 million) and for COPD (8 million) (Table 2). The total annualized medical expenditures for treated asthma-related medical events among workers were $7 billion, and they were $5 billion for COPD. Derived using the pooled population-attributable fraction of 16% for asthma and 14% for COPD ( 3 ), annualized expenditures attributable to workplace exposures exceeded $1 billion for asthma and $700 million for COPD. TABLE 2 Estimated number of workers with asthma-related or chronic obstructive pulmonary disease–related medical event and annualized total and per-person expenditures,* by type of event and source of payment — Medical Expenditure Panel Survey, United States, 2011–2015 Event/Source of payment† Asthma Chronic obstructive pulmonary disease Total no. of events No. of workers with an event (x1,000) Total expenditures ($) in millions Average expenditure ($) per person Total no. of events No. of workers with an event (x1,000) Total expenditures ($) in millions Average expenditure ($) per person Total § 21,206 7,920 7,137 901 14,540 7,371 5,021 681 Type of event Prescription drugs 15,008 5,361 5,216 973 8,421 3,733 1,627 436 Office based visits 5,503 2,117 921 435 5,262 3,064 1,041 340 Inpatient visits 66 63 519 8,238 71 62 1,711 27,597 Emergency department visits 412 332 372 1,121 441 375 442 1,178 Outpatient visits 210 126 106 841 293 205 166 810 Home health visits 8 8 3 375 52 21 35 1,667 Source of payment Private insurance 16,917 5,331 4,326 811 9,235 4,173 2,949 707 Out of pocket¶ 22,907 6,673 1,370 205 14,489 5,993 664 111 Medicaid 3,011 977 681 697 1,859 647 391 604 Medicare 2,473 635 446 702 2,399 775 761 983 Other** 2,109 583 314 556 1,437 592 256 432 * All medical expenditures expressed in 2017 U.S. dollars. † More than one type of medical event and source of payment could be reported per person. § Columns do not sum to totals because of rounding. ¶ Portion of total payments made by persons or families for services received during the year, including deductibles, coinsurance, and copayments for covered services plus all expenditures for services not covered by the insurance. ** Includes payments from the Department of Veterans Affairs (excluding TRICARE); other federal sources (Indian Health Service, military treatment facilities, and other care provided by the Federal Government); various state and local sources (community and neighborhood clinics, state and local health departments, and State programs other than Medicaid); payments from Workers' Compensation; and, other unclassified sources (e.g., automobile, homeowner's, or liability insurance, and other miscellaneous or unknown sources). It also includes private insurance payments reported for persons without private health insurance coverage during the year, as defined in the Medical Expenditure Panel Survey, and Medicaid payments reported for persons who were not enrolled in the Medicaid program at any time during the year (https://meps.ahrq.gov/mepstrends/hc_cond/ ). By type of medical event, prescription drugs for asthma ($5 billion) and inpatient visits for COPD ($2 billion) accounted for the highest total annualized expenditures. Annualized expenditures per person were highest for inpatient visits (excluding prescription medications): $8,238 for asthma and $27,597 for COPD. By source of payment, private health insurance paid for 61% ($4 billion) of expenditures attributable to treated asthma and 59% ($3 billion) of expenditures attributable to treated COPD. The highest annualized expenditures per person were paid by private insurance for asthma ($811) and Medicare for COPD ($983). Among industry groups, the annualized expenditures per person for treated asthma were highest among public administration workers ($1,279), followed by transportation and utilities workers ($1,222) (Table 3). The annualized expenditures per person for treated COPD were highest among public administration workers ($1,819), followed by construction workers ($1,198). TABLE 3 Estimated number of workers with an asthma-related or chronic obstructive pulmonary disease–related medical event and annualized total and per-person expenditures,* by industry groups among workers aged ≥18 years payment — Medical Expenditure Panel Survey, United States, 2011–2015 Industry group No. of workers (x1,000) Asthma Chronic obstructive pulmonary disease No. of workers with an event (x1,000) Total expenditures ($) in millions Average expenditure ($) per person No. of workers with an event (x1,000) Total expenditures ($) in millions Average expenditure ($) per person Natural resources 2,320 57 47 825 96 36 375 Mining 792 40 46 1,150 —† — — Construction 10,500 221 214 968 344 412 1,198 Manufacturing 16,354 658 733 1,114 874 614 703 Wholesale and retail trade 21,400 1,005 940 935 821 404 492 Transportation and utilities 7,771 284 347 1,222 349 155 444 Information 3,306 155 136 877 137 76 555 Financial activities 10,142 435 363 834 416 180 433 Professional and business services 19,592 957 773 808 806 327 406 Education health and social services§ 38,507 2,421 2,250 929 2,004 1,435 716 Leisure and hospitality 14,492 691 555 803 552 383 694 Other services¶ 8,515 363 324 893 398 199 500 Public administration§ 8,247 535 684 1,279 469 853 1,819 Military 355 — — — — — — Unclassifiable/Missing 4,054 — — — — — — *All medical expenditures expressed in 2017 U.S. dollars. † Unreliable estimates (relative standard error >30; standard error of the estimate divided by the estimate), data suppressed. § Includes education services workers and ambulatory healthcare services workers, hospitals, nursing and residential care facility workers and social assistance. § https://datausa.io/profile/naics/92. ¶ Other services industries include repair and maintenance, personal and laundry services, religious, grantmaking, civic, professional services, and private households and similar organizations. Discussion COPD and asthma combined were among the top five most costly medical conditions among U.S. adults in 2012 ( 4 ). Among workers, the total medical expenditures attributable to the treatment of asthma and COPD were substantial ($7 billion for asthma and $5 billion for COPD) and varied by sociodemographic characteristics and industry. Workers in the public administration industry (e.g., police officers, correctional officers, jailers, firefighters, and secretaries and administrative assistants) §§ had the highest annualized per-person expenditures for both asthma and COPD. In the public administration industry, an estimated 7.4% of workers have asthma, and 3.5% of workers have COPD. ¶¶ Variation in expenditures by industry might reflect the differences in prevalences, health insurance status, and access to medical care. Overall, workers with no health insurance had lower medical expenditures for asthma and for COPD than did those who had health insurance, suggesting that the uninsured population might have sought services through free clinics or might have limited their care-seeking ( 1 , 3 ). Based on the 2019 pooled population attributable fraction estimates of 16% for asthma and 14% for COPD, the estimated expenditures attributable to workplace exposures among workers exceeded $1 billion for asthma and $700 million for COPD. Among workers, prescription medications accounted for the highest proportion of total medical expenditures attributable to the treatment of asthma, as did inpatient visits for the treatment of COPD, similar to previous findings among all U.S. adults ( 1 , 5 ). Inpatient visits accounted for the highest per-person expenditure for treated asthma and COPD. Higher expenditures related to inpatient visits have been highly correlated with asthma and COPD exacerbation severity ( 5 , 6 ). An estimated 67% of total asthma-attributable medical expenditures were associated with prescription medications, which is higher than the 51% observed previously among all U.S. adults ( 1 ). The higher prescription medication expenditures might be associated with new and more costly treatment options or could be a result of inflation adjustments ( 1 , 7 , 8 ). Moreover, workers are more likely to have health insurance than are nonworkers ( 9 ); therefore, they might have fewer financial barriers to purchasing prescription medications, which might also partially explain the higher expenditures among workers. The findings in this report are subject to at least four limitations. First, the number of medical events and expenditures associated with asthma and COPD were self-reported by respondents and might be subject to recall bias. However, self-reported medical events and expenditure data, including office-based visits, emergency department visits, and hospitalizations, have been shown to correspond well with health care utilization data ( 10 ). Second, workers could have been treated for comorbidities during their asthma- or COPD-related medical encounter; therefore, a portion of medical expenditures might not be directly associated with asthma or COPD. Third, workers might have changed employment from the industry in which they were employed at the time of their asthma- or COPD-related medical events; therefore, medical expenditures by industry group might not reflect the actual industry the worker was employed in when the expenditure was incurred. Finally, small sample sizes for some groups resulted in unreliable estimates. Annualized overall and per-person medical expenditures attributable to treated asthma and treated COPD among workers were substantial. Early identification and reduction of risk factors, including workplace exposures (e.g., vapors dusts gas and fumes), and implementation of proven interventions are needed to reduce the adverse health and economic impacts of asthma and COPD among workers. Prioritizing intervention efforts aimed at preventing asthma and COPD among workers, especially among those with higher medical costs, by supporting workplace programs and policies (e.g., smoke-free workplace policies, smoking cessation programs, and workplace exposure control measures) can reduce the impact of disease and improve worker health.*** Continued surveillance is important to identify workers with high prevalences of asthma or COPD and less consistent access to health care. Summary What is already known about this topic? Asthma and chronic obstructive pulmonary disease (COPD) are associated with substantial economic and health costs among U.S. workers. What is added by this report? During 2011–2015, total annualized medical expenditures among U.S. workers were $7 billion ($901 per person) for asthma and $5 billion ($681 per person) for COPD. Inpatient visits were associated with the highest average per-person expenditures for both conditions. Insured workers incurred higher expenditures than did uninsured workers. What are the implications for public health practice? Early identification and reduction of risk factors, including workplace exposures (e.g., vapors, gas, dusts, and fumes), and implementation of proven interventions are needed to reduce the adverse health and economic impacts of asthma and COPD among workers.

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          How accurate are self-reports? Analysis of self-reported health care utilization and absence when compared with administrative data.

          To determine the accuracy of self-reported health care utilization and absence reported on health risk assessments against administrative claims and human resource records. Self-reported values of health care utilization and absenteeism were analyzed for concordance to administrative claims values. Percent agreement, Pearson's correlations, and multivariate logistic regression models examined the level of agreement and characteristics of participants with concordance. Self-report and administrative data showed greater concordance for monthly compared with yearly health care utilization metrics. Percent agreement ranged from 30% to 99% with annual doctor visits having the lowest percent agreement. Younger people, males, those with higher education, and healthier individuals more accurately reported their health care utilization and absenteeism. Self-reported health care utilization and absenteeism may be used as a proxy when medical claims and administrative data are unavailable, particularly for shorter recall periods.
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            The Occupational Burden of Nonmalignant Respiratory Diseases. An Official American Thoracic Society and European Respiratory Society Statement

            Rationale: Workplace inhalational hazards remain common worldwide, even though they are ameliorable. Previous American Thoracic Society documents have assessed the contribution of workplace exposures to asthma and chronic obstructive pulmonary disease on a population level, but not to other chronic respiratory diseases. The goal of this document is to report an in-depth literature review and data synthesis of the occupational contribution to the burden of the major nonmalignant respiratory diseases, including airway diseases; interstitial fibrosis; hypersensitivity pneumonitis; other noninfectious granulomatous lung diseases, including sarcoidosis; and selected respiratory infections. Methods: Relevant literature was identified for each respiratory condition. The occupational population attributable fraction (PAF) was estimated for those conditions for which there were sufficient population-based studies to allow pooled estimates. For the other conditions, the occupational burden of disease was estimated on the basis of attribution in case series, incidence rate ratios, or attributable fraction within an exposed group. Results: Workplace exposures contribute substantially to the burden of multiple chronic respiratory diseases, including asthma (PAF, 16%); chronic obstructive pulmonary disease (PAF, 14%); chronic bronchitis (PAF, 13%); idiopathic pulmonary fibrosis (PAF, 26%); hypersensitivity pneumonitis (occupational burden, 19%); other granulomatous diseases, including sarcoidosis (occupational burden, 30%); pulmonary alveolar proteinosis (occupational burden, 29%); tuberculosis (occupational burden, 2.3% in silica-exposed workers and 1% in healthcare workers); and community-acquired pneumonia in working-age adults (PAF, 10%). Conclusions: Workplace exposures contribute to the burden of disease across a range of nonmalignant lung conditions in adults (in addition to the 100% burden for the classic occupational pneumoconioses). This burden has important clinical, research, and policy implications. There is a pressing need to improve clinical recognition and public health awareness of the contribution of occupational factors across a range of nonmalignant respiratory diseases.
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              The economic impact of exacerbations of chronic obstructive pulmonary disease and exacerbation definition: a review.

              Chronic obstructive pulmonary disease (COPD) poses a significant economic burden on society, and a substantial portion is related to exacerbations of COPD. A literature review of the direct and indirect costs of COPD exacerbations was performed. A systematic search of the MEDLINE database from 1998-2008 was conducted and supplemented with searches of conference abstracts and article bibliographies. Articles that contained cost data related to COPD exacerbations were selected for in-depth review. Eleven studies examining healthcare costs associated with COPD exacerbations were identified. The estimated costs of exacerbations vary widely across studies: $88 to $7,757 per exacerbation (2007 US dollars). The largest component of the total costs of COPD exacerbations was typically hospitalization. Costs were highly correlated with exacerbation severity. Indirect costs have rarely been measured. The wide variability in the cost estimates reflected cross-study differences in geographic locations, treatment patterns, and patient populations. Important methodological differences also existed across studies. Researchers have used different definitions of exacerbation (e.g., symptom- versus event-based definitions), different tools to identify and measure exacerbations, and different classification systems to define exacerbation severity. Unreported exacerbations are common and may influence the long-term costs of exacerbations. Measurement of indirect costs will provide a more comprehensive picture of the burden of exacerbations. Evaluation of pharmacoeconomic analyses would be aided by the use of more consistent and comprehensive approaches to defining and measuring COPD exacerbations.
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                Author and article information

                Journal
                MMWR Morb Mortal Wkly Rep
                MMWR Morb. Mortal. Wkly. Rep
                WR
                Morbidity and Mortality Weekly Report
                Centers for Disease Control and Prevention
                0149-2195
                1545-861X
                03 July 2020
                03 July 2020
                : 69
                : 26
                : 809-814
                Affiliations
                Respiratory Health Division, National Institute for Occupational Safety and Health, CDC; Office of the Director, National Institute for Occupational Safety and Health, CDC.
                Author notes
                Corresponding author: Girija Syamlal, gos2@ 123456cdc.gov , 304-285-5827.
                Article
                mm6926a1
                10.15585/mmwr.mm6926a1
                7332099
                32614807
                06450e1f-684d-4da7-8c25-0821a3c8b44c

                All material in the MMWR Series is in the public domain and may be used and reprinted without permission; citation as to source, however, is appreciated.

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