BURDEN OF
COPD
IN ROMANIA
FLORIN DUMITRU MIHALTAN
RUXANDRA ULMEANU
IRINA STRIMBU
NATIONAL INSTITUTE OF PNEUMOLOGY
“MARIUS NASTA” BUCHAREST - ROMANIA
SUMMARY
INTRODUCTION
EPIDEMIOLOGY STUDIES
RISK FACTORS
COMPLIANCE TO GUIDELINES?
EXACERBATIONS AND COSTS OF COPD IN ROMANIA
THERAPY IN AMBULATORY
REIMBURSEMENT OF THE COPD TREATMENT IN ROMANIA
CONCLUSIONS
FUTURE DEMANS
INTRODUCTION
Why Romania has his own problem
• Prevalence study?
• Risk factors ?
• Compliance to guidelines?
• Cost of disease and exacerbations?
• The hospitalised and ambulatory problems
• Reimbursement of medication?
EPIDEMIOLOGY STUDIES
Morbidity and mortality
in comparison
with other countries
Duţu St, Păun G. – Prevalenţa simptomelor respiratorii, a astmului bronşic şi bronşitei cronice (simple şi obstructive) într-un eşantion reprezentativ de populaţie adultă rurală. Pneumoftiziologia 1998, Jul-Sep, 47(3): 151-160.
4,60%2,30%
MALE
FEMALE
COPD PREVALENCE IN ROMANIA
IN 1998
ROMANIA - COPD INCIDENCE – 2004 - GP MISSDIAGNOSIS
21485
6
12821
4918
0
5000
10000
15000
20000
25000
To t al 0 - 14 15- 6 4 ≥6 5
Source: Centrul de Statistica Medicala si Documentare MedicalaRegistrul National de boli pulmonare cronice 2005,fara numar pagina
27212
0
16860
10352
0
5000
10000
15000
20000
25000
30000
Tot al 0 - 14 15- 6 4 ≥6 5
Source: Centrul de Statistica Medicala si Documentare MedicalaRegistrul National de boli pulmonare cronice 2005,fara numar pagina
ROMANIA - COPD INCIDENCE – 2004 - SPECIALISTS DIAGNOSIS-also internal medicin -
Duţu St, Păun G. – Prevalenţa simptomelor respiratorii, a astmului bronşic şi bronşitei cronice (simple şi obstructive) într-un eşantion reprezentativ de populaţie adultă rurală. Pneumoftiziologia 1998, Jul-Sep, 47(3): 151-160.
ROMANIA – MORTALITY RATE
Chronic Obstructive Diseases - 1998
5,00%OOO
20,00%OOO
MALE
FEMALE
RISK FACTORS
SMOKING HABITS
Irina Strambu: “BPOC – Astm bronsic: abord terapeutic si costuri in Romania”, 2006, Teza de doctorat, UMF “Carol Davila”, Bucuresti
ROMANIA 2006
COPD Exacerbation – Hospitalisation
Smoking Habits of the patients
21%
39%
28%
12%
Unsmokers
Ex/smokers
Smokers
Not mention
Average of 20 package / year
• More Smoker as in EU
• Quitters less as in EU
15%057%11%--031%RO
Without answer
Alt răspuns (spontan)
Have you ever smoke
You tried to renounce
Prizaţi sau mestecaţi tutun
Fumaţi pipă sau trabuc
Fumaţi ţigări pe care le faceţi singur
Smoking cigarettes from packs
Are you smoking at home?
RO: 91% yes
Second place in EU
after Hungary
Compliance to guidelines?
COPD- WHAT IS PRESCRIBED IN
EUROPE?
M. Rudolf: The Reality of Drug Use in COPD. The European Perspective Chest 2000;117;29-32
GREAT BRITAIN
BETA ADREN. 40%
INHAL CORTICOIDS 20%
ANTICOLINERG. < 20%
70% from the whole
prescription
GERMANY, AUSTRIA
• ANTICOUGH SI MUCOLITICS 35%
• METILXANTINE 20%
ITALIE
• METILXANTINS -40%
• ANTIB.AND ANTICOUGH-25%
• BETA 2 ADRENERGICS < 20%
COPD- WHAT IS PRESCRIBED IN ROMANIA ?
V. Golli, Ileana Băzăvan, Andreea-Loredana Golli - Sondaj asupra măsurilor preconizate în BPOC.
Pneumoftiziologia 1998, vol. XLVII, nr. 2, 83-88
QUESTIONNAIRE FOR GP, PNEUMOLOGIST,
INTERNISTS IN 1998
(308 PATIENTS)
WHAT THEY PREFER AS TREATMENT
FOR COPD ?
WHAT MEDICATION IS
PRESCRIBED IN ROMANIA - 1998?
V. Golli, Ileana Băzăvan, Andreea-Loredana Golli - Sondaj asupra măsurilor preconizate în BPOC.
Pneumoftiziologia 1998, vol. XLVII, nr. 2, 83-88
THEOPHYLLINE - most part of prescription
- 1/3 parenteral I.V. !!
BETA 2 ADRENERGICS INHALING - Majority of pneumologists
- ½ of internists
- few GP
INHALING CORTICOTHERPY – Majority of pneumologists
SYSTEMIC CORTICOID – Internists, GP
4%
6%
16%
30%
39%
42%
64%
66%
72%
73%
81%
83%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90%
Antitusive
Teofiline i.v.
Simpatomimetice cu acţiune lungă
Anticolinergice
Corticoizi parenteral
Corticoizi oral
Corticoizi sistemici
Fluidifiante de mucus
Corticoizi inhalatori
Antibiotice
Teofiline orale (retard)
Simpatomimetice cu acţiune scurtă
WHAT ARE THE PRESCRIPTIONS IN THE HOSPITAL -2004
Irina Strambu: “BPOC – Astm bronsic: abord terapeutic si costuri in Romania”, 2006, Teza de doctorat, UMF “Carol Davila”, Bucuresti
EXACERBATIONS
AND COSTS OF COPD
IN ROMANIA
FRANCE
SPAIN
HOLAND
UK
Country
Scope study - B. Detournay, C. Pribil, M. Fournier, B. Housset, G. Huchon, D. Huas, P. Godard, C. Voinet, I. Chanal, Colette Jourdanne, I. Durand-Zaleski, the SCOPE Group - The SCOPE Study: Health-Care Consumption Related to Patients with Chronic Obstructive Pulmonary Disease in France. Value in
Health Volume 7 Issue 2 Page 168 - March 2004
4366 €/PATIENT
41% MONITORING
25% COMPLICATION
34% COMORBIDITIES
1/3 Hospital
1/3 DRUGS
2004
Miravitlles M, Murio C, Guerrero T, Gisbert R. - Costs of chronic bronchitis and COPD: a 1-year follow-up study. Chest. 2003
Mar;123(3):784-91.
1876 €/PATIENT
43% Hospital
40% Drugs
15% Diagnosis Tests
2003
Rutten-Van Mo¨ lken MP et al. Current and future medical cost of asthma and chronic obstructive pulmonary disease in the Netherlands. Respiratory Medicine, 1999, 93 (11): 779–787.
813$/PATIENT1999
National Health Service Executive. Burdens of disease: a discussion document. Leeds, United Kingdom; Department of
Health, 1996
1154 ₤(2300$)/PATIENT/year
47,5% Drugs
24% Oxyg.
18% Hospital
10% GM
1996
SourceCOSTSYear
Source: Centrul de Statistica Medicala si Documentare MedicalaRegistrul National de boli pulmonare cronice 2005,fara numar pagina
134 179 151 239 523
3064
18714
16434
22912
11892
851
0
5000
10000
15000
20000
25000
<1 1-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 >85
BPOCTOTAL: 75093MALE: 49936
ROMANIA - COPD – 2004 - HOSPITALIZATION
HEALTH CARE COSTS OF EACH OF THE ABOVE 4 SMOKING RELATED DISEASES BY AGE AND SEX-PER PATIENT
ROMANIA - 2004
Source: Centrul de Calcul si Statistica Sanitara –BucurestiAnuar de Statistica Sanitara 2005, Cheltuieli sanitare, pag.263
1337.7
1576.3
1530.2
1336.1
1200
1250
1300
1350
1400
1450
1500
1550
1600
Cancer
bronhopulmonar
Boli cerebro-
vasculare
BPOC Cardiopatii
ischemice
COPD DRUGS – SALES-UNITS – ROMANIA 2006
4884336111461
856840
34669
293448
7261
155558
12345
12083
704114
0 500000 1000000 1500000 2000000 2500000 3000000 3500000 4000000 4500000 5000000
ALL XANTHINES
BECOTIDE+BECLOFORTE
EURESPAL
FLIXOTIDE
SERETIDE
SEREVENT
SINGULAIR
SPIRIVA
SYMBICORT
VENTOLIN INHALER
COPD COSTS IN ROMANIA
EVALUATION OF EXACERBATIONS COSTS
IN A HOSPITAL OF SUPERIOR LEVEL AS THE
NATIONAL INSTITUTE OF PNEUMOLOGY “MARIUS NASTA”
RETROSPECTIVE STUDY
JAN – SEPT. 2002
181 PACIENTS
DIAGNOSIS COPD “EXACERBATION”
Irina Strambu: “BPOC – Astm bronsic: abord terapeutic si costuri in Romania”, 2006, Teza de doctorat, UMF “Carol Davila”, Bucuresti
27,5%
72,5%
FEMALE
MALE
2004
COPD EXACERBATION – HOSPITALISATION
OVER 75% ARE SMOKERS
Irina Strambu: “BPOC – Astm bronsic: abord terapeutic si costuri in Romania”, 2006, Teza de doctorat, UMF “Carol Davila”, Bucuresti
2004COPD EXACERBATION – HOSPITALISATION
Distributed by urban or rural areal
52%48%URBANRURAL
Irina Strambu: “BPOC – Astm bronsic: abord terapeutic si costuri in Romania”, 2006, Teza de doctorat, UMF “Carol Davila”, Bucuresti
COPD PREVALENCE IS HIGHER IN TOWNS
RURAL AREA ARE “COMPENSATING”
There is an important pressure to hospitalized
the patients for diagnosis and investigation
with a reduced accessibility or inaccessible in
ambulatory
2004
COPD EXACERBATION – HOSPITALISATION
Irina Strambu: “BPOC – Astm bronsic: abord terapeutic si costuri in Romania”, 2006, Teza de doctorat, UMF “Carol Davila”, Bucuresti
STAGE I-III Similar stay period STAGE IV Long period of hospitalization
Duration of hospitalisation
15,6 15,8414,94
21,12
17,18
0
5
10
15
20
25
STADIUL I STADIUL II STADIUL III STADIUL IV MEDIA
ZILE DE SPITALIZARE
2004
COPD EXACERBATION – HOSPITALISATION
Irina Strambu: “BPOC – Astm bronsic: abord terapeutic si costuri in Romania”, 2006, Teza de doctorat, UMF “Carol Davila”, Bucuresti
HEALTH CARE COSTS OF EACH OF THE ABOVE 4 SMOKING RELATED DISEASES BY AGE AND SEX
ROMANIA – 2004-Average of hospitalisation days
Source: Centrul de Calcul si Statistica Sanitara –BucurestiAnuar de Statistica Sanitara 2005, Cheltuieli sanitare, pag.263
8.41
9.919.62
8.4
7.5
8
8.5
9
9.5
10
Cancer
bronhopulmonar
Boli cerebro-
vasculare
BPOC Cardiopatii
ischemice
Media zilelor de spitalizare
2004AVERAGE HOSPITALIZATION PERIOD : 17 DAYS
Significant longer as in US < 6 days
SPAIN - 11 days
COPD – MORE SEVERE - 42% STAGE IV
LONGER PERIOD OF HOSPITALIZATION (21 DAYS)����
• SEVERE INFECTIONS PATHOGENS • OROTRACHEAL INTUBATED CASES • INVAZIVE MECHANICAL VENTILATION• CPAP
15 DAYSEVEN TO PATIENTS WITH EASY STAGING – WHY?
Irina Strambu: “BPOC – Astm bronsic: abord terapeutic si costuri in Romania”, 2006, Teza de doctorat, UMF “Carol Davila”, Bucuresti
BLOOD GAS ANALYSES - 37% RESPIRATORY FAILURE
6% 24% 28% 42%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
STADIUL I STADIUL II STADIUL III STADIUL IV
Staging of the patients
2004
COPD EXACERBATION – HOSPITALISATION
Irina Strambu: “BPOC – Astm bronsic: abord terapeutic si costuri in Romania”, 2006, Teza de doctorat, UMF “Carol Davila”, Bucuresti
MOST PART OF HOSPITALIZED PATIENTS
ARE IN STAGE III AND IV
“THE OTHERS” “ARE CARRING ” THE DISEASE UNDIAGNOSED
0
20
40
60
80
100
120
140
160
180
200
181 PACIENTI STADII III+IV
70%
Irina Strambu: “BPOC – Astm bronsic: abord terapeutic si costuri in Romania”, 2006, Teza de doctorat, UMF “Carol Davila”, Bucuresti
CO-MORBIDITIES
43% 16% 21% 20%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
CARDIOVASCULAR DIABET ZAHARAT SECHELE TBC BROSIECTAZII
2004
COPD EXACERBATION – HOSPITALIZED
Irina Strambu: “BPOC – Astm bronsic: abord terapeutic si costuri in Romania”, 2006, Teza de doctorat, UMF “Carol Davila”, Bucuresti
DIRECT COSTS – LABS INVESTIGATIONS
• MINIMAL – SIMPLE SPIROMETRY
• MAXIMAL – SEVERE PATIENT - ICU
REPETEATED MONITORING BLOOD GAS ANALYSIS
UNTIL 72 BLOOD GAS ANALYSIS / PATIENT
2004
COPD EXACERBATION – HOSPITALIZED
Irina Strambu: “BPOC – Astm bronsic: abord terapeutic si costuri in Romania”, 2006, Teza de doctorat, UMF “Carol Davila”, Bucuresti
DIRECT COSTS – LAB INVESTIGATIONS
20
5519
2769.5
0
1000
2000
3000
4000
5000
6000
MINIM MAXIM MEDIE
(RON)
COPD EXACERBATION – HOSPITALIZED
Irina Strambu: “BPOC – Astm bronsic: abord terapeutic si costuri in Romania”, 2006, Teza de doctorat, UMF “Carol Davila”, Bucuresti
2004 COPD
COSTS OF LAB INVESTIGATIONS
DISCREET RAISING FROM ONE STAGE TO OTHER
IMPORTANT DIFFERENCES ARE JUSTIFIED FOR STAGE IV
? ARE ALL INVESTIGATION NECESSARY
- SPUTUM FOR B.KOCH
(MICROSCOPY AND CULTURE TO NEW HOSPITALIZED PATIENTS )
-SPUTUM FOR OTHER BACTERIAL AGENTS
EXACERBATION / COMMUNITY INFECTIONS
WITH WELL KNOWN GERMS
DRUG COSTS
DRUGS FOR COPD
DRUGS FOR OTHER COMORBIDITIES
174,4
180,8
235,4
245,9
363,8
369,6
703,4
724,7
431
443,5
0
100
200
300
400
500
600
700
800
STADIUL I STADIUL II STADIUL III STADIUL IV MEDIE
BPOC TOTAL
2004
COPD EXACERBATION – HOSPITALIZED
Irina Strambu: “BPOC – Astm bronsic: abord terapeutic si costuri in Romania”, 2006, Teza de doctorat, UMF “Carol Davila”, Bucuresti
���� PROGRESIVE OF THE COST IN THE SAME TIME WITH THE WORSENING OF THE DISEASE
� TOTAL COSTS OF THE DRUGSEXCLUSIVELY THROUGH ���� SPECIFIC DRUGS
FOR COPD
SOFISTICATED ANTIBIOTICS
PARENTERAL CORTICOIDS
ANTITROMBOTICS
COSTS OF DRUGS
“OLD” REFLEX THERAPEUTIC
FIRST DRUG , SOMETIMES FOR
THE WHOLE PERIOD OF HOSPITALIZATION
CORTICOID IM, IV
IS THE PARENTERAL TREATMENT
SUPERIOR TO THE ORAL ONE?
EXCESS OF ANTIBIOTICS
TO 73% OF PATIENTS
VERY FREQUENTLY
AMOXYCILIN – CLAVULANAT
VERY OFTEN MORE THAN 7 DAYS
IN INTENSIVE UNITS
CEFALOSPORINE, PENEMS .etc.
Irina Strambu: “BPOC – Astm bronsic: abord terapeutic si costuri in Romania”, 2006, Teza de doctorat, UMF “Carol Davila”, Bucuresti
Average costs per different stages
470 531 550 1129 727
0
200
400
600
800
1000
1200
STADIUL I STADIUL II STADIUL III STADIUL IV MEDIA
EURO
2004
COPD EXACERBATION – HOSPITALIZED
Irina Strambu: “BPOC – Astm bronsic: abord terapeutic si costuri in Romania”, 2006, Teza de doctorat, UMF “Carol Davila”, Bucuresti
TOTAL COSTS PER PATIENTS
DISTRIBUTED BY STAGING
0
5000
10000
15000
20000
25000
30000
35000
40000
mii lei
std I std II std III std IV
investigations
treatment
loging
total
COSTS OF TREATMENT IS
<1/3 FROM THE TOTAL!
Irina Strambu: “BPOC – Astm bronsic: abord terapeutic si costuri in Romania”, 2006, Teza de doctorat, UMF “Carol Davila”, Bucuresti
EVEN IF THE PATIENTS WHERE HOSPITALIZED FOR
COPD EXACERBATION
ONLY 70% RECEIVED SYSTEMIC CORTICOID AND/OR
ANTIBIOTICS
¾ RECEIVED INHALING CORTICOIDS
60% RECEIVED MUCOLYTICS
DOCTORS ARE DOING THE THERAPY IN CONECTION TO
DIAGNOSIS AND NOT TO THE STAGING OF DISEASE
PRESCRIPTION OF DRUGS FOR COPD
(IN HOSPITAL)
THE REST OF 30%
ONLY WITH THE BASIC TREATMENT
WITH THE HOPE THAT
THE PATIENT WILL CONTINUE
THE THERAPY IN AMBULATORY
2004
COPD EXACERBATION – HOSPITALIZED
PARENTERAL TEOPHYLINE VERY LOW
USED IN THE HOSPITAL
THEY PREFFERED SHORT ACTING
INHALER BRONCHODILATATOR
IN THE ACUTE BRONCHOSPASM
PRESCRIPTION OF DRUGS FOR COPD(IN HOSPITAL)
THERAPY
IN AMBULATORY
PRESCRIPTION BEFORE HOSPITALISATION IN AMBULATORY
8%
16%
23%
38%
43%
45%
45%
78%
0% 10% 20% 30% 40% 50% 60% 70% 80%
ANTIBIOTICOTERAPIE PROFILACTICA
CORTICOTERAPIE SISTEMICA
ANTICOLINERGICE ASOCIAT ALTOR
BRONHODILATATOARE
VACIN ANTIGRIPAL
BRONHODILATATOARE DE LUNGA
DURATA + CORTICOIZI INHALATORI
TEOFILINE RETARD
AMINOFILINA
BRONHODILATATOARE CU ACTIUNE
SCURTA
Irina Strambu: “BPOC – Astm bronsic: abord terapeutic si costuri in Romania”, 2006, Teza de doctorat, UMF “Carol Davila”, Bucuresti
PRESCRIPTION BEFORE HOSPITALISATION IN
AMBULATORY
THERAPY IS NOT REGULARY
THE PATIENTS WERE TREATED
IN AVERAGE
6 MONTH /YEAR
WHAT MEDICATION IS
PRESCRIBED IN ROMANIA - 1998 ?
V. Golli, Ileana Băzăvan, Andreea-Loredana Golli - Sondaj asupra măsurilor preconizate în BPOC.
Pneumoftiziologia 1998, vol. XLVII, nr. 2, 83-88
ONLY 36% OF THE DOCTORS
ARE MONITORING REGULARY
THEIR PATIENTS
REIMBURSEMENT OF THE COPD
TREATMENT IN ROMANIA
COPD exacerbation
INCOMES OF THE HOSPITALIZED PATIENTS
MAJORITY OVER 80% - INCOMES < 200 RON/MONTH
11% WITHOUT ANY KIND OF INCOMES !
1819
34
38 38
5
7
21
12
0
5
10
15
20
25
30
35
40
nr.
pacie
nti
0 0,5 1 1,5 2 2,5 3 3,5 5,5 ?
milioane lei lunar
Irina Strambu: “BPOC – Astm bronsic: abord terapeutic si costuri in Romania”, 2006, Teza de doctorat, UMF “Carol Davila”, Bucuresti
MAJORITY 80% - INCOMES < 60 €/MONTH
11% WITHOUT INCOMES !
POSIBILITY TO RECEIVED A CORRECT CHRONIC THERAPY?
NO
A CHRONIC DISEASE WITHOUT TREATMENT
APPARENCE OF AN EXACERBATION
FOR EXACERBATION POSSIBILITY TO BE TREATED IN AMBULATORY?
NO (FOR RETIRED PERSONS NO POSSIBILITY OF
CHRONIC THERAPY)
THE PATIENT IS COMING
TO THE HOSPITAL
WE CANNOT REFUSE
THE HOPITALISATION
ROMANIA – COPD THERAPY
NOT FREE OF CHARGE
CONCLUSIONS
CONCLUSIONS
NOT ALL HOSPITALISED COPD PATIENTS ARE WITH
EXACERBATIONS
HOSPITALIZATION LONGER AS IN OTHER
COUNTRIES
AVERAGE COSTS OF HOSPITALISATION IT’S UNDER
THE COSTS IN DEVELOPED COUNTRIES
727 EURO/PATIENT 2599 EURO/PATIENT*
ROMANIA EUROPE
*Lopez-Campos Bodineau JL, Fernandez Guerra J, Lara Blanquer A, Perea-Milla Lopez E, Moreno L,Cebrian Gallardo JJ, Garcia Jimenez JM – Analysis of admissions for chronic obstructive pulmonary disease in Andalusia in 2000. Arch Bronconeumol 2002 Oct;38(10):473-8.
CONCLUSIONS
THE MAJORITY OF THE PATIENTS
STAGE III AND IV
FEV1 < 50%
70% FROM OUR HOSPITALISED PATIENTS
ARE CONSUMING 80% FROM OUR
RESOURCES
CONCLUSIONS
COPD – HOSPITAL
MORE THAN ½ OF THE COSTS
IS FOR HOSPITALIZATION ITSELF!
CONCLUSIONS
TREATMENT COSTS
FOR THE HOSPITALIZATION < 1/3
FROM THE TOTAL COSTS OF
AN EXACERBATION
CONCLUSIONS
FUTURE DEMANDS
PAY ATTENTION TO :
• HOSPITALISATION CRITERIA
• THE PERIOD OF HOSPITALISATION
���� INCOMES FOR RURAL POPULATION
���� TREATMENT IN THE HOSPITAL
���� DURATION OF THE HOSPITALISATION
FUTURE DEMANDS
� QUALITY OF LIFE
���� EXACERBATIONS
� RATE OF SURVIVAL
HOW CAN WE APPLIED THIS IN ROMANIA ?
CHRONIC TREATMENT WELL DONE
REIMBURSEMENT – FREE OF CHARGE
HOME OXIGENOTHERAPY
FUTURE DEMANDS
REIMBURSEMENT –INSURANCE SYSTEM
COPD - AMBULATORY THERAPY – LOW COSTS
REIMBURSEMENT PART /GLOBAL
FOR
LONG TERM HOME OXYGENOTHERAPY
EXACERBATION TREATED IN AMBULATORY
FACILITY FOR PATIENTS TRANSPORT IN MEDICAL
SPECIALISED DEPARTMENTS
FUTURE DEMANDS
REIMBURSEMENT OF THE DRUGS
STUDIES OF EVALUATION COSTS-EFFICACY
MONITORING COPD-LOW COSTS
DEVELOPING THE AMBULATORY MONITORING
SYSTEM
AVOIDING HOSPITALIZATION
HOW WE CAN SOLVED THE PROBLEM
OUR ACTUAL PROBLEMS ARE :
• FEW PREVALENCE STUDY-WITHOUT A VERY GOOD DESIGN
• UNDERESTIMATION OF THE DISEASE
• SMOKING STILL A HUGE PROBLEM UNSOLVED
• COMPLIANCE TO ACTUAL GUIDELINES
• REIMBURSEMENT OF MEDICATION
• AMBULATORY DEFICIENCY