Chronic obstructive pulmonary disease in patients under age 65: utilization and costs from a managed care sample.

OBJECTIVES: Chronic obstructive pulmonary disease (COPD) affects all adult age groups, not just elderly males. We assessed the health care utilization and cost impact of COPD in different age groups. METHODS: We compared burden of illness, utilization, and charges for younger versus older COPD patients and versus age- and gender-matched controls. RESULTS: A total of 16.9% of patients with COPD were under age 65. Patients with COPD (n=19,338) had higher comorbidity than age-matched controls (n=94,384) across all age groups. Younger patients with COPD had lower comorbidity scores and fewer hospitalizations but more COPD-related emergency services than older patients with COPD. Average COPD-related charges were higher for younger patients. Facility-based care was the cost driver across all age groups. CONCLUSIONS: COPD is a burden to younger individuals in the workforce, who are likely to be enrolled in a commercial health plan.

Improving the management of chronic obstructive pulmonary disease.

As the fourth leading cause of death in the United States, chronic obstructive pulmonary disease (COPD) represents a major burden to the healthcare system and society at large. Underdiagnosis and undertreatment lead to an increased economic burden, with exacerbations being a key driver of costs. COPD symptoms compromise quality of life (QOL), which affects both patients and caregivers. Appropriate management decreases healthcare utiization and improves QOL. This article provides an overview of COPD and promotes understanding of opportunities to optimize patient health and outcomes for those with the disease. Specific interventions that have been demonstrated to improve clinical and economic outcomes for COPD include improved implementation of guidelines, optimized pharmacologic treatment, and risk-factor reduction.

The impact of chronic obstructive pulmonary disease on long-term disability costs.

OBJECTIVES: Chronic obstructive pulmonary disease (COPD) as a cause of disability with subsequent costs remains poorly recognized. The small, growing body of literature on COPD shows that it is one of the leading causes of missed work.greater than asthma or diabetes. However, much less is known about the impact of COPD on long-term disability (LTD). Because the health care burden for disabled, working-age patients will fall heavily on managed care organizations, better estimates of the economic and pharmacoeconomic costs of COPD are required. We seek to improve understanding of the burden of COPD on several national LTD programs. METHODS: We reviewed occupational health and disability literature and government statistics to determine how long-term, respiratory-related disability is addressed by disability pension programs in 8 developed countries (Canada, France, Germany, Italy, Japan, Spain, the United Kingdom, and the United States). We then applied respiratory-specific disability definitions to country-specific population and pension information to estimate the potential burden of COPD on LTD insurance programs in each country. RESULTS: Comprehensive, relevant data to evaluate respiratory-related disability are lacking. Of the study countries, only the United States has explicit respiratory specific criteria for disability eligibility, which are based solely on spirometry. We estimate that the total burden of COPD in the study countries may range from 5 billion dollars to as high as 25 billion dollars per year if all persons who met U.S. eligibility criteria for respiratory-related disability were granted compensation. CONCLUSION: The potential burden of COPD on LTD programs may be large. The lack of standard criteria for respiratory-related disability may lead to underrecognition of COPD's true potential impact. Further work is needed to develop consistent and cost-effective ways to measure the impact of COPD and to assist in disability determination for COPD patients.

Characterization of ischemic events and use of prescription antiplatelet and anticoagulant agents after stroke or transient ischemic attack.

Stroke patients are at risk for subsequent ischemic events; yet preventive therapy is often underused. An analysis was performed to determine the rate of secondary ischemic events and use of prescription antiplatelets or anticoagulants after ischemic stroke or transient ischemic attack (TIA). Patients age 25 years or older with a medical claim for stroke or TIA between July 1, 1998 and September 30, 1999 were identified from a managed care database. Patients sustaining a stroke or TIA within 6 months before the index event were excluded. Patients were categorized as hospitalized stroke, nonhospitalized stroke, or TIA and were followed for 24 months for a secondary stroke, TIA, or acute myocardial infarction (AMI). Use of prescription antiplatelet or anticoagulant agents was determined for each subgroup. Over 2 years, subsequent stroke occurred in 5.8% of patients, TIA occurred in 3.8%, and AMI occurred in 4.9%. Death occurred in 32.3% during follow-up. Hospitalized stroke patients were the subgroup at highest risk, with a 7.6% stroke rate and a 45.4% death rate within 2 years. Prescription antiplatelet or warfarin therapy was given in 45.7% of hospitalized stroke cases, 29.5% of nonhospitalized stroke cases, and 39.2% of TIA cases. Against the background of current treatment, patients who suffer a stroke or TIA are at high risk of death and a subsequent stroke within 2 years. These outcomes highlight the importance of effective secondary stroke prevention efforts for those suffering acute stroke, whether or not they are hospitalized.

Effects of generic-only drug coverage in a Medicare HMO.

Rising pharmacy costs and demand for prescription drug coverage for broader populations of seniors have resulted in the implementation of generic-only pharmacy benefits in Medicare health maintenance organizations (HMOs). The impact on cost and quality of care is unknown. We examined data for members of a California Medicare HMO whose coverage changed to a generic-only benefit and found that the change was associated with reduced health plan pharmacy cost, increased out-of-pocket pharmacy costs for members, increased overall hospital admissions, changed drug-use patterns, and a negative impact on quality metrics for certain conditions. These findings have important implications for future research and health policy decisions.

Chronic obstructive pulmonary disease treatment options.

OBJECTIVE: To discuss current therapies for the treatment of chronic obstructive pulmonary disease (COPD) and their efficacy and use according to current treatment guidelines. SUMMARY: The overall approach to the management of stable COPD is a stepwise increase in treatment, depending on disease severity. Inhaled bronchodilators are the cornerstone of symptomatic management of COPD and include beta 2-agonists, anticholinergics, and methylxanthines. Short-acting beta 2-agonist bronchodilators (e.g., albuterol) have a quick onset of action and are useful for rescue. Long-acting bronchodilators are taken on a regular basis to prevent or reduce symptoms and include beta 2-agonists saleterol and formoterol and anticholinergics ipratropium bromide and tiotropium bromide. Methylxanthines have decreased in usage due to potential toxicity. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines are an international initiative, updated in 2003. GOLD staging consists of 5 levels of severity; treatment guidelines recommend a step-wise approach, with short- and long-acting bronchodilators as the cornerstone of therapy. CONCLUSION: Appropriate pharmacologic treatment of symptomatic COPD can result in reduced patient limitations and health care utilization and improved health-related quality of life.

The cost of chronic obstructive pulmonary disease and its effects on managed care.

Chronic obstructive pulmonary disease (COPD) designates respiratory disorders characterized by airway obstruction that is not fully reversible. An estimated 10 million adult Americans have COPD, and the prevalence is rising. Direct and indirect costs of managing COPD exceed dollars 32 billion annually, and this health care burden has provoked vigorous efforts by major public health organizations to evaluate and improve quality of care for COPD. The authors review the substantial effects of COPD on managed care and discuss evidence-based strategies for its effective management.

Interpreting COPD prevalence estimates: what is the true burden of disease?

STUDY OBJECTIVES: To summarize the available data on COPD prevalence and assess reasons for conflicting prevalence estimates in the published literature. DESIGN: We reviewed published studies that (1) estimated COPD prevalence for a population, and (2) clearly described the methods used to obtain the estimates. RESULTS: Thirty-two sources of COPD prevalence rates, representing 17 countries and eight World Health Organization-classified regions, were identified and reviewed. Prevalence estimates were based on spirometry (11 studies), respiratory symptoms (14 studies), patient-reported disease (10 studies), or expert opinion. Reported prevalence ranged from 0.23 to 18.3%. The lowest prevalence rates (0.2 to 2.5%) were based on expert opinion. Sixteen studies had measured rates that could reasonably be extrapolated to an entire region or country. All were for Europe or North America, and most fell between 4% and 10%. CONCLUSIONS: There is considerable variation in the reported prevalence of COPD. The overall prevalence in adults appears to lie between 4% and 10% in countries where it has been rigorously measured. Some of the variation attributed to differences in risk exposure or population characteristics may be influenced by the methods and definitions used to measure disease. Spirometry is least influenced by local diagnostic practice, but it is subject to variation based on the lung function parameters selected to define COPD.

Worldwide guidelines for chronic obstructive pulmonary disease: a comparison of diagnosis and treatment recommendations.

OBJECTIVE: Chronic obstructive pulmonary disease (COPD) is a leading cause of worldwide burden of disease, but is underdiagnosed and undertreated. We performed a systematic review of worldwide COPD clinical practice guidelines (CPG) to determine the degree of international consensus on major guideline recommendations. METHODS: The COPD CPG were identified from the medical literature and through contact with respiratory experts and organizations. An abstraction form was developed to collect information related to COPD diagnosis and management. RESULTS: Locally developed COPD CPG are based upon expert consensus, but do not explicitly rate the strength of the evidence for recommendations. The detail and clarity of the 41 CPG varied regarding the diagnosis and management of COPD. Key differences included the lung function parameters that define a diagnosis and severity assignment of COPD. The use of anticholinergics, alone or in combination, was listed as a consideration for first-line therapy for persistent COPD in all 41 CPG. There was consensus regarding reserving corticosteroids for selected patients. CONCLUSIONS: There is variation and ambiguity within COPD CPG regarding specific recommendations that can be applied by clinicians at a patient-specific level. The variation in CPG for COPD may contribute to the underdiagnosis and suboptimal treatment of COPD. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) workshop report may help resolve some of the variation surrounding COPD diagnosis and treatment. However, local guideline implementation efforts must assist physicians in applying guideline recommendations to support patient-specific management.