SEATTLE—Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in the United States, and it affects twice as many Americans as does diabetes.[1] The costs attributable to the treatment of COPD are currently estimated to be $30.4 billion annually.[2] And these costs only promise to rise as the baby boomer generation grows older.

Investigators from the Department of Pharmacy of the University of Washington in Seattle, Kaiser Permanente Center for Health Services Research in Portland, Oregon, and Glaxo Wellcome, Inc (now GlaxoSmithKline) in Research Triangle Park, North Carolina, reviewed the results of the 1987 National Medical Expenditure Survey (NMES) in a study published this year.[3] According to this new study, the 228 community-based patients with COPD who responded to four questionnaires during 1987 spent $6,469 (mean, per person; in 1987 US dollars) on direct medical expenditures, of which 25% was related to their COPD.

“Health care providers generally think of people with COPD as being ill and using a lot of health care resources,” said Scott A. Strassels, PharmD, an outcomes researcher at the University of Washington and lead author of the paper. “Not only did we find that this was true, but we also found that people with COPD are likely to have other diseases that also exert a large societal, medical, and economic burden.”

The patients included in Dr. Strassels’ study were predominantly male, white, ages 65 years or older, had smoked at some point in their lives, and reported three or more comorbidities (Table 1).

• About 68% of total direct medical expenditures were for inpatient hospitalizations; each COPD patient spent an average of five days in the hospital that year.

• Patients with COPD reported 24.4 bed days, 27.5 restricted-activity days, and 3.6 lost workdays, of which approximately 66%, 58%, and 28%, respectively, were COPD-related.

• Approximately 20% of outpatient clinic visits, 22% of visits to specialists, and 36% of visits to generalists were COPD-related.

• Women used more resources than did men on a per-person basis.

The NMES survey was conducted more than a dozen years ago, before the advent of nicotine gum for smoking cessation and widespread use of ipratropium bromide metered-dose inhalers. Confronting C.O.P.D. in America, a recently released national survey funded by GlaxoSmithKline and conducted by Schulman, Ronca, and Bucuvalas, Inc, explored the societal impact of COPD today.[4] The findings are backed by the American Lung Association, American College of Chest Physicians, National Lung Health Education Program, and American Association of Respiratory Care.

Nearly 600 patients 45 years or older who were diagnosed with or determined to have symptoms of COPD were interviewed over the telephone. These patients were identified through random-digit dialing of a probability sample of 27,000 American households. The survey evaluated the frequency and severity of symptoms, health care utilization, disease management and treatment, and the patients’ quality of life. Nearly half of those interviewed reported dyspnea while accomplishing common tasks, such as dressing or light housework. About a third said they experienced shortness of breath while talking, sitting, or lying still.

“I don’t think there has been much change since the 1987 NMES survey in how COPD affects Americans today,” said Dr. Strassels. Treatment for COPD is still largely geared toward symptom relief and support, he added, with the exceptions of [lung] transplantation, lung volume reduction surgery, and pulmonary rehabilitation.

While the impact that COPD has on its sufferers and the approach toward their treatment may not have changed, what have changed are the demographics. COPD is often considered to be a disease mostly of older male smokers. Yet the survey found that more women than men had COPD (60% vs 40%, respectively). It also discovered that half those diagnosed with COPD are younger than 65 years. In fact, 22% of those polled were younger than 55 years, and their average age at diagnosis was 53 years.

Emergency visits during the year prior to this latest survey revealed another cost of the disease. Of the patients in the survey, 14% had been hospitalized overnight, 19% reported they had visited the emergency department, and 26% had had other emergency visits. The frequency of urgent care visits was higher in the younger patients (ages 45 to 54 years): 27% of them reported visits to the emergency department and 32% had other unscheduled emergency visits. The survey supported clinical observations that symptoms tend to worsen as the patient ages.

However, younger survey respondents ranked their symptoms as more severe than did the older patients. This may be because younger patients have a more acute awareness of their symptoms and lower tolerance of the burden.

The COPD patients overwhelmingly agreed that their physicians are attentive and knowledgeable, and that they include them in decision making. In contrast, however, a third said that their physicians don’t understand their suffering and that their physicians blame them for the poor health habits (eg, smoking) that led to development of the disease.

Dr. Strassels thinks health care professionals and patients have to be more proactive in fighting COPD. “In terms of treatment, efforts to keep people out of the hospital are most likely to be cost effective,” he said. The American Lung Association estimates that today $14.7 billion is expended on direct COPD-related health care costs; an additional $15.7 billion is spent on indirect expenditures.[3] However, “the most important steps are those [that] help prevent COPD in the first place, like smoking cessation,” said Dr. Strassels. “Once people have the disease, we have to play catch-up.”

Is there another solution? Better education, according to the latest survey, which reported that COPD patients and their physicians differ in their outlooks on symptom severity and condition status. Survey results also showed that most patients overestimate the degree of their symptom control: 42% of them said their condition has been “completely” or “well” controlled during the previous year but often alluded to a period of time when they were short of breath every day. Further, 24% said their condition restricts them “a lot” in normal physical exertion. The survey authors believe that as long as patients don’t realize their conditions can be better controlled, they will not seek the care they need.

—Martha L. Heckel

References
1. Murphy SL. Deaths: Final Data for 1998. National Vital Statistics Report. Vol 48. Hyattsville, Md: National Center for Health Statistics; 2000. No 11.

2. American Lung Association Fact Sheet: Chronic Obstructive Pulmonary Disease (COPD). January 2001. Available at: http://www.lungusa.org/disease/copd_factsheet.html. Accessed May 4, 2001.

3. Strassels SA, Smith DH, Sullivan SD, Mahajan PS. The costs of treating COPD in the United States. Chest. 2001;119:344-352.

4. Schulman, Ronca, and Bucuvalas, Inc. Confronting COPD in America. Available at: http://www.lungusa.org/press/lung_dis/asn_copd21601.html. Accessed May 4, 2001.

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