Although not discussed as often as diabetes, heart disease, or even oncology, chronic obstructive pulmonary disease (COPD) is a significant, challenging disease state for managed care organizations in 2011. According to a study presented at the American Thoracic Society’s 2006 annual meeting, the US medical costs related to COPD are expected to total approximately $832.9 billion between 2006 and 2026.1
Approximately 12 million Americans have COPD, which is second only to heart disease as a disability forcing employees to quit working.2 As recently reported by the Centers for Disease Control and Prevention, COPD is now the third most common cause of mortality in the United States,3,4 accounting for more than 120,000 annual deaths.1 The mortality rate from COPD has increased more than 60% over the past 20 years, with more than 95% of all COPD-related deaths being those aged >55 years.2 COPD affects more women than men, but the mortality rates are approximately the same for both sexes.2
The mortality rates for COPD are greater in whites than nonwhites and also greater in blue-collar workers than white-collar workers.2 These are sobering statistics about a serious and disabling illness that is often under diagnosed and undertreated. In 2006 it was estimated that close to 13 million Americans had been diagnosed with COPD, but 24 million people had the disease, indicating substantial underdiagnosis.5,6
This report highlights data related to COPD presented at the 2010 annual meeting of the American College of Chest Physicians (ACCP 2010), with a focus on new and emerging therapies, as well as data presented at ACCP 2010 that show that the cost of care for COPD escalates based on GOLD (Global Initiative for Chronic Obstructive Lung Disease) severity criteria.
According to the study by M. Reza Maleki-Yazdi, MD, FRCPC, FCCP, and colleagues discussed in this publication, almost half of the cost of care for COPD is related to exacerbations of the disease. This study shows that the average annual COPD-related cost per patient is $4147 in Canada, and that the cost rises to $6141 for those with GOLD stage 4 COPD. Of that $6141, $2631 results from exacerbations of the illness, and $3510 is maintenance cost, according to this study.
A study presented at ACCP 2010 by Andrew P. Yu, PhD, and discussed in this supplement, is based on realworld information that is derived from a robust claims database with nearly 23,500 patients with COPD. From this study we learn that increased patient adherence to COPD therapies is strongly associated with reduced mortality and hospitalization risks for patients with COPD.
We also learn that the use of a more complex routine of multiple inhalers compared with single inhalers results in lower adherence to medication, and this lower adherence is associated with a total healthcare cost increase of $3319 for these patients.
Clearly these are negative cost implications related to the severity of disease and medication nonadherence. One can certainly hypothesize that the combination of severe disease, which is likely to need more complex care, and the associated nonadherence seen with more complex care, may have a negative cost impact on the healthcare system.
This publication also presents information about new therapies in the pipeline for the treatment of COPD. The cornerstones of therapy for this condition remain bronchodilation and reduction of inflammation. To that end, ultra–long-acting beta-agonists, such as indacaterol, carmoterol, vilanterol, or olodaterol, may soon offer clinicians and payers alternatives to currently available bronchodilators. Roflumilast (Daxas), an oral phosphodiesterase 4 inhibitor, shows promise in reducing inflammation in patients with COPD. However, it remains to be determined if any of these newer agents will offer clinical advantages over existing therapies.
So where do we go from here? We know that health plans and physicians must work together to help improve outcomes and control the cost of this progressive and debilitating disease. New medications and new guidelines alone are not enough to change clinical outcomes and “bend the cost curve.” A systemwide approach involving all stakeholders is necessary to improve outcomes in this patient population.
Successful health plans may therefore need to consider the following approaches to managing COPD:
Improving diagnosis
- Does the health plan have processes in place to ensure that members with COPD are properly diagnosed?
- The plan must also be able to demonstrate to their employers that diagnosing patients with previously undiagnosed COPD will have a major impact on future costs
- Improving treatment
- Does the health plan have processes in place to ensure that its members are receiving recommended treatments according to guidelines? As we have learned in this supplement, optimal care for those already diagnosed can result in substantial improvements in symptoms and quality of life, as well as reductions in medical expenses
Improving outcomes
Plans with disease management programs for COPD must be able to demonstrate that the education and adherence support provided to patients with COPD ultimately results in decreases in hospitalizations, emergency department visits, admissions to the intensive care unit, unscheduled office visits, and acute exacerbations; if this cannot be shown, the programs need to be assessed and re designed to achieve these end points
Working with employers
Prevention at the worksite: smokefree work environments and careful adherence to occupational safety procedures can reduce exposure to environmental pollutants that increase the risk of COPD or worsen symptoms for those with the disease
Education: campaigns to increase employee awareness of the symptoms of COPD (eg, shortness of breath is not a normal part of getting older and should be brought to the attention of a physician) and the impact of smoking, which can improve early detection of COPD
COPD screening: programs to encourage lung function testing for those at high risk for COPD will improve early detection
Patient programs: smoking cessation programs can help reduce the incidence of COPD. Once an employee has been diagnosed with COPD, one-on-one case management programs can be effective.
Several important conclusions are relevant to the health plan perspective concerning the management of COPD. First, the number of patients with COPD is still growing as a result of the aging of the population and the significant time it takes to see the effect of reduced rates of smoking on the prevalence of COPD. Second, the cost of caring for individuals with COPD is likely to increase as this patient group increases. Therefore, it is imperative to manage guidelines and use the most effective treatments available. Third, it is important that we have new treatment options in the quest to better manage patients with COPD.
And yet, pharmaceutical innovation alone will not result in better management of COPD. In addition to new treatment options, we must better understand how to help patients improve their medication adherence. Finally, helping physicians to manage these patients according to well-established guidelines will continue to be a major challenge.
To adequately manage patients with COPD and to control the clinical and economic consequences of this disease, an equal amount of effort needs to be invested in finding new treatments, managing patients to established guidelines, educating physicians, working with employers, and better understanding how to motivate patients to comply with care routines. Only by involving all stakeholders in this process will we be able to improve clinical outcomes and control costeffectively in patients with COPD.
References
- Medical News Today. COPD will cost U.S. over $800 billion over next 20 years. May 30, 2006. www.medicalnewstoday.com/articles/44235.php. Accessed January 8, 2011.
- The Merck Manual. Chronic obstructive pulmonary disease. www.merckmanuals.com/home/sec04/ch045/ch045a.html. Accessed January 11, 2011.
- Centers for Disease Control and Prevention. Strokes drops to fourth leading cause of death in 2008. Press Release. December 9, 2010. www.cdc.gov/media/pressrel/2010/r101209.html. Accessed January 4, 2011.
- Centers for Disease Control and Prevention. National Center for Health Statistics, 1960-2010. www.cdc.gov/nchs/data/about/nchs_50th_brochure. pdf. Accessed January 4, 2011.
- Pleis JR, Lethbridge-Cejku M. Summary health statistics for U.S. adults: National Health Interview Survey, 2005. Vital Health Stat 10. 2006;232:1-153.
- Yawn BP. Differential assessment and management of asthma vs chronic obstructive pulmonary disease. Medscape J Med. 2009;11:20.