Economic Burden of COPD
Chronic obstructive pulmonary disease is one of the leading “prosperity diseases”
worldwide. Pooled global prevalence rates based on clinical assessments and spirometry
ranged from 7.6 to 8.9%, reported in a sound meta-analytical study design (1). It
has far reaching consequences, not only for an affected patient’s health but also
for the entire national health systems (2). These refer to the substantial work load
for the medical facilities due to chronic clinical course of illness and modest success
of available treatment approaches. COPD attributable resource utilization patterns
are particularly substantial if large university tertiary care hospitals, specialist
clinics, and intensive care units are observed (3). According to most of published
evidence the key cost driver are periodic exacerbations followed by intensive care
unit admissions and episodes of infectious complications (4). Among major cost domains,
physician consultations and surgery dominate in high-income settings. Unlike in the
West, within the most of South Eastern European region, COPD medical care is still
dominated with acquisition costs of pharmaceuticals and oxygen (5) and imaging diagnostics
(6). Outpacing of indirect productivity-related opportunity costs by the direct costs
of in- and outpatient medical care is common to this region due to substantially lower
wages of physicians and nursing staff (7). Apart from direct costs of COPD, mainly
constituted from the resources consumed in the health care process, including costs
of ambulatory care, drug treatment, hospital care, rehabilitation, and long-term home
care, there are substantial indirect costs of COPD, which are incurred by productivity
losses, premature retirement, and premature mortality from this disease. The indirect
costs for premature mortality are being calculated through human capital approach,
with the life years lost up to the age of 65 multiplied by the gross annual income.
An insight into the economic reality of SEE region, particularly Serbia, with average
wages significantly lower than in countries of the Western Europe, but at the same
time with high unemployment rates in younger age groups, where some 50% of the working
population is currently outside of the workforce (8), being in their most productive
decades of life but at the same time most prevalent tobacco users, makes indirect
cost of COPD in SEE region very difficult to calculate or even predict, but clearly
shows significant magnitude of this burden in present years, and probable rise of
these costs in the future. Intangible costs are not convertible into monetary terms
and units, they are specifically related to the distress and suffering, which is caused
by the disease. General lack of insight into patients’ perception of the disease and
limitation and incapability, which it imposes, while healthcare workers are being
focused mainly on physical burden of the disease, with very few patients being provided
with structurised psychosocial aid in the attempt to overcome significant yet underestimated
mental and emotional burden of the disease, makes these costs impossible to predict
and foresee.
An Example of Serbia’s Health Reforms
Serbia as the largest Western Balkans upper-middle income market began health reforms
one decade later than most transitional countries of SEE region (9, 10). After dynamic
2000–2007 GDP increase and overall development, the issue of long-term sustainability
of its health system financing became hot topic under the first strike of global recession
(11). Large part of almost unbearable economic burden was attributable to the major
prosperity diseases including pulmonary diseases (12). The unique common weakness
revealed by all of these pioneering cost-of-illness assessments in the Balkans region
was poor health system responsiveness to population needs together with overextended
hospital budgets and accumulating of public depth generated by the national health
insurance fund (13). An occurrence of catastrophic household expenditure triggered
by severe illness, sinking entire families into poverty is still prevalent within
the society (14). Expensive medical technologies, which were denied reimbursement,
remained mostly unaffordable to the ordinary citizens (15).
Consequences of COPD Relative to Population Aging and Comorbid Disorders
Populations across Eastern Europe and the Balkans are aging even more rapidly than
their Western European counterparts. This population aging is likely to further constrain
already limited resource allocation in health care (16). This happens mostly due to
dwindling base of employed tax payers in their most productive life time combined
with increased proportion of the elderly. Demand for medical services by the retired
citizens is significantly higher compared to working, younger age groups and this
is particularly the case within the last year of life (17). Substantial impact of
age to the COPD costs of care was already claimed in literature. Clinical severity
of disease according to the Global initiative for chronic Obstructive Lung Disease
(GOLD) classification, clearly correlated with resource use and costs of hospital
and outpatient care (18).
In an exploration of long-term pharmaceutical market transformation trends in Western
Balkans, it has been observed that agents used to treat COPD exhibited prominent rise
in market share during the past decade. Reported value based turnover of medicines
intended to treat respiratory disorders grew from € 17,090,000 in 2004 to the € 46,500,000
in 2012 (19). It is a paradox that during same 9 years unit drug consumption in terms
of defined daily doses DDD/1000 inhabitants/day actually fell from 164.55 in 2004
to 50.55 level in 2012 [according to Anatomical Therapeutic Chemical (ATC) classification
(“R” ground code group)] (20). Explanation for this shift in Balkan pharmaceutical
markets should be looked within stronger brand penetration and modest success of generic
pharmaceuticals in many therapeutic areas (21). COPD-related prescription and dispensing
of β-adrenergic preparations in combination with inhalatory corticosteroids (“R03AK”
ATC code group) were reported record breaking fivefold increase from € 2,682,320 in
2004 toward € 11,761,775 in 2012 based on latest official release by the National
Medicines and Medicinal Device Agency of Serbia (22). Recent dissertation conducted
on health economics of community acquired pneumonia (CAP), proved clear proof of substantial
COPD comorbidity impact to the overall costs of medical care. While ordinary CAP clinical
cases incurred on average € 717 costs in a 1 month time horizon while the ones suffering
from COPD and CAP incurred € 970 monthly costs of inpatient care (23).
Proposed Measures to Tackle the Challenges Lying Ahead
Although COPD prevalence and incidence seem to be steadily slowing down in some parts
of the European region, this might not be the case with mortality rates. Unfortunately,
COPD will most likely be the third leading cause of death worldwide and the fifth
leading cause of years lost through early mortality or handicap (disability-adjusted
life years) in 2020, which is far worse landscape compared to 1990 (24). So far serious
policy initiatives to combat decreased longevity and quality of life caused by COPD
have been taken both by WHO and the European COPD Coalition (ECC) (25). Orchestrated
supranational efforts to increase research investment in the therapeutic options for
COPD were proposed within the Horizon 2020 framework as well (26).
Broad forecasts on COPD for the South Eastern European region may be significantly
less optimistic compared to the traditional EU15 economies (see Table 1). Some underlying
reasons are strong popular affection toward smoking tobacco among adolescents (27,
28) and inefficiencies of anti-tobacco public health campaigns and policies (29).
Environmental pollution plays less significant role due to shutting down of most heavy
industries in former socialist countries (30) due to socioeconomic transition as well
as their lack of global competitiveness (31). Popular opinion on tobacco is gradually
beginning to change but this is likely to be a lengthy process. Additional obstacles
to this tobacco reduction process seem to be traditionally high prevalence of tobacco
smoking habit in Balkan countries such as Bulgaria (32) and FYR Macedonia (33) and
heavy investment of global multinational tobacco manufacturers in Serbia and Turkey
in particular (34). Essential revenues provided to the local governments by taxation
of tobacco sales both to the industry and the consumers is still too important to
the regional economies, still outside EU, such as Western Balkans and Turkey. This
fact makes tobacco control policies currently in place less successful. Opposingly,
promising trend of decreasing tobacco consumption is clearly visible in the OECD economies
such as Greece (35), Slovenia, Hungary, and Cyprus where smoking free legislation,
higher taxes on cigarettes, and facilitated access to medicines used to treat nicotine
addiction are being applied for a number of years in line with the EU health priority
targets (36). According to combined tobacco control score (TCS), most countries of
South Eastern European region obtained <50 grades with the exceptions of Ukraine and
Turkey. Interestingly, unsatisfactory and weak tobacco control policies remain in
place in a number of traditional high-income European economies.
Table 1
Ground indicators on respiratory disorders, tobacco consumption, and health expenditures
in SEE 1980–2010.
Country
AL
BA
BG
HR
CY
GR
HU
MN
MD
RO
RS
SK
SI
MK
TR
UA
SDR, bronchitis/emphysema/asthma, all ages, per 100,000 – 1980
26.081987
36.771985
41.91
27.861985
12.892004
20.64
62.15
1.72000
20.11981
71.71
28.671998
31.971986
14.741985
40.251991
N/A
26.571981
SDR, bronchitis/emphysema/asthma, all ages, per 100,000 – 2010
13.072004
15.332011
10.45
21.06
9.31
0.17
31.1
0.122009
42.3
20.5
23.04
13.09
12.2
18.74
35.83
31.162004
SDR, selected smoking-related causes, per 100,000 – 1980
262.811987
269.461985
544.43
353.881985
158.332004
292.22
566.24
243.382000
844.851996
461.93
382.431998
440.381992
347.761985
335.441991
N/A
637.251991
SDR, selected smoking-related causes, per 100,000 – 2010
324.092004
237.582011
345.25
349.9
128.09
183.07
425.16
180.622009
762.36
427.69
332.47
416.46
185.02
331.21
232.04
774.792004
Hospital discharges, respiratory system diseases, per 100,000 – 1980
1954.461989
850.83
2743.52
1351.221981
773.5
1193.82
1854.341992
1678.871988
3830.1
3089.9
812.192000
1958.951991
1721.4
970.651983
329.85
4930.78
Hospital discharges, respiratory system diseases, per 100,000 – 2010
1331.93
855.921989
3098.79
998.13
599.762008
1536.892007
1685.35
1275.22
2467.71
2817.71
1106.06
1471.01
1410.742009
1863.55
1781.6
3704.3
Prevalence of chronic obstructive pulmonary disease (%) – 1980
0.151994
3.14
2.6
0.411981
N/A
0.35
0.121988
N/A
1.31991
0.491989
N/A
1.021994
N/A
0.171983
N/A
2.761996
Prevalence of chronic obstructive pulmonary disease (%) – 2010
0.21
1.56
2.252000
0.14
N/A
0.242008
1.47
N/A
N/A
1.47
N/A
1.68
N/A
0.382007
N/A
3.94
Number of cases of chronic obstructive pulmonary disease – 1980
48701994
128449
230335
187451981
N/A
34117
372781990
N/A
568781991
1138141989
N/A
545451994
N/A
33591983
N/A
14036401996
Number of cases of chronic obstructive pulmonary disease – 2010
6874
59968
1841672000
6200
N/A
265952008
147480
N/A
N/A
315437
N/A
91023
N/A
77372007
N/A
1799851
% Of regular daily smokers in the population, age 15+ – 1980
29.51990
37.62002
31.41986
32.61995
23.92003
461991
441992
N/A
192000
25.91989
332000
24.41992
341988
N/A
441988
401990
% Of regular daily smokers in the population, age 15+ – 2010
39
14.3
39.72007
27.42003
26.52008
31.92009
31.42009
32.72008
27.12006
26.72011
26.22006
19.42009
19.22012
361999
25.4
23.3
Number cigarettes consumed per person per year – 1980
436.191996
820.821997
1880.95
21671992
N/A
2271.4
2652.39
N/A
N/A
1347.071991
N/A
1715.051993
2500.541996
2143.111996
1167.44
N/A
Number cigarettes consumed per person per year – 2010
744.062000
1244.012000
2792.62000
1736.682000
N/A
3200.492004
2151.412000
N/A
N/A
1392.631997
N/A
1230.42000
2232.862000
1794.362000
1547.841998
10272000
Sulfur dioxide emissions, kg per capita per year – 1980
N/A
107.191990
231.34
32.72
N/A
41.48
152.46
N/A
76.78
47.52
N/A
156.49
123.41
N/A
4.59
77.14
Sulfur dioxide emissions, kg per capita per year – 2010
N/A
N/A
104.772000
15.982000
N/A
50.012000
53.862000
N/A
31.612000
40.121994
N/A
38.882000
13.572000
52.31998
15.492000
46.912000
Average annual concentration of sulfur dioxide (SO2) in capital, μg/m3 – 1980
N/A
18.42002
27.41998
N/A
N/A
22.21997
41.61997
N/A
N/A
N/A
58.62003
25.41997
35.41997
27.31997
N/A
N/A
Average annual concentration of sulfur dioxide (SO2) in capital, μg/m3 – 2010
38.52009
35.1
9.4
N/A
N/A
5.72008
6.7
N/A
N/A
15
37.8
19.5
22008
1.3
12.6
N/A
Average annual concentration of particulate matter <10 μm (PM10) in the capital, μg/m3
– 1980
N/A
N/A
20.42000
N/A
N/A
34.72001
352003
N/A
N/A
N/A
52.72004
36.51999
30.92002
N/A
N/A
N/A
Average annual concentration of particulate matter <10 μm (PM10) in the capital, μg/m3
– 2010
22.62009
48.5
48.4
N/A
N/A
30.42007
31.9
N/A
N/A
35.4
23.1
26.6
29.42009
N/A
59.5
N/A
Average annual concentration of nitrogen dioxide (NO2) in capital, μg/m3 – 1980
N/A
272002
39.72003
N/A
N/A
50.81997
53.21997
N/A
N/A
N/A
40.22003
34.31997
31.62002
N/A
N/A
N/A
Average annual concentration of nitrogen dioxide (NO2) in capital, μg/m3 – 2010
N/A
25.7
31.3
N/A
N/A
42.42008
28.1
N/A
N/A
20.52011
27.9
13.3
34.7
152009
N/A
N/A
Average annual concentration of ozone (O3) in the capital, μg/m3 – 1980
N/A
68.42006
4.41999
N/A
N/A
75.81997
691997
N/A
N/A
N/A
65.42004
721998
661998
N/A
N/A
N/A
Average annual concentration of ozone (O3) in the capital, μg/m3 – 2010
N/A
53.6
65.4
N/A
N/A
88.62008
73.72009
N/A
N/A
57.7
71.22011
71.6
63.7
N/A
N/A
N/A
Total health expenditure, PPP$ per capita, WHO estimates – 1980
97.61995
128.441955
290.221995
546.041995
722.761995
1263.11995
656.741995
445.181995
115.121995
183.441995
259.861995
503.81995
969.41995
421.41995
174.121995
246.561995
Total health expenditure, PPP$ per capita, WHO estimates – 2010
481.9
833.74
1053.1
1461.7
2221.68
2584.6
1653.88
947.86
369.66
880.94
1183.44
2088.18
2366.4
772.02
1071.54
520.44
Containing epidemiological burden of COPD in the Balkans, while providing equitable
and affordable medical care for patients will demand surmounting efforts from local
communities. Economic consequences in terms of illness attributed lost productivity
are huge and due to ongoing upward economic developments in the area likely to increase
further. Current national capacities in SEE health care provision remain insufficient,
not only in terms of professional staff but also in terms of specialized clinics and
rehabilitation facilities, which are still scarce across the region (37). Through
the course of past decades, historical network of facilities created to combat tuberculosis
was seriously downsized due to successes of innovative vaccines and antibiotics. Another
important issue is strong concentration of clinical physicians and nurses in urban
cores, leaving rural areas underserved (38).
Far reaching potentially successful strategy to combat COPD in South Eastern Europe
would have several distinct features. Such effort should be supranational and should
contain key priorities defined within common EU policy on COPD (39). It would have
to include peculiarities of local public health and clinical settings, which were
already proven to affect resource use and outcomes of COPD medical care (40). Major
measures assume prevention of smoking among youth and controlling environmental pollution
primarily in large cities. Timely detection of illness by broadly targeted diagnostic
screenings could allow more efficient treatment and preserving clinical evolution
in its early stages. Evidence based allocation, favoring implementation of cost-effective
diagnostic and treatment protocols would help to contain cost without significant
adverse influence to the quality of care. Such a complex approach could allow larger
portion of local communities to be taken care for, particularly among the poor and
underserved citizens.
Although the quantification of the direct health care costs of COPD as well as indirect
and intangible costs in these countries is very difficult, it is clear that pulmonary
specialists across the South Eastern Europe region are challenged to increase their
efforts to reduce the menace of smoking and to put in additional efforts in creation
of new strategies aimed at early diagnostics. The estimation of total health care
costs can therefore only be a first step in assessing the overall impact of COPD burden
in South East Europe region. Further studies on the economic burden of COPD, including
the perspective of mostly underestimated indirect and intangible costs within the
region will be needed to prove and justify the prevention and early diagnostics efforts
and development of new strategies of reduction of both financial and non-financial
burden of disease. Many policy makers are starting to realize that a more robust evidence
base is needed in order to make informed decisions on resource allocation. In light
of current weaknesses of regional health financing, funding the quest for knowledge
of the local cost drivers of key clinical conditions represents a valuable investment
in the future of emerging markets (41).
COPD with its multimillion patient population in the SEE region should be regarded
as one of the high-profile policy issues on the agenda of national health ministries
and governmental agencies. Future of these patients remains particularly unpredictable
among the small Western Balkan economies approaching EU membership.
Conflict of Interest Statement
The author declares that the research was conducted in the absence of any commercial
or financial relationships that could be construed as a potential conflict of interest.