Burden of Copd in Romania Florin Dumitru Mihaltan

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

i obstructive) ş MALE 4,60%

itei cronice (simple ş

i bron ş

ic ş

. Pneumoftiziologia Jul-Sep, 1998, 151-160. 47(3): ă

rural ă

IN 1998 IN ie adult ţ

a simptomelor a respiratorii, astmului bron ţ

antion reprezentativ de popula ş COPD PREVALENCE IN ROMANIA ROMANIA IN PREVALENCE COPD

un G. – Prevalen ă FEMALE 2,30% într-un e

u St, P ţ

Du ROMANIA - COPD INCIDENCE – 2004 - GP MISSDIAGNOSIS

2 5 0 0 0 21485

2 0 0 0 0

12821 15 0 0 0

10 0 0 0 4918

5 0 0 0 6

0 Total 0-14 15-64 ≥65

Source: Centrul de Statistica Medicala si Documentare Medicala Registrul National de boli pulmonare cronice 2005,fara numar pagina ROMANIA - COPD INCIDENCE – 2004 - SPECIALISTS DIAGNOSIS -also internal medicin -

27212 30000

25000

16860 20000

15000 10352

10000

5000 0 0 Total 0-14 15-64 ≥65

Source: Centrul de Statistica Medicala si Documentare Medicala Registrul National de boli pulmonare cronice 2005,fara numar pagina OOO i obstructive) ş MALE 20,00%

itei cronice (simple ş

i bron ş

ic ş

. Pneumoftiziologia Jul-Sep, 1998, 151-160. 47(3): ă

rural ă

ie adult ţ OOO

a simptomelor a respiratorii, astmului bron ţ ROMANIA – MORTALITY RATE 5,00% FEMALE

antion reprezentativ de popula ş Chronic Obstructive Diseases - 1998

un G. – Prevalen ă

într-un e

u St, P ţ

Du RISK FACTORS

SMOKING HABITS Unsmokers Ex/smokers Smokers mention Not

i costuri in Romania”, 21% 39% Average of 20 package / package year of 20 Average ROMANIA 2006 ROMANIA

2006, Teza2006, Bucurest “Carol Davila”, UMF de doctorat, 12% Smoking Habits of the patients Smoking Habits Irina Strambu: “BPOC Irina– Strambu: Astm bronsic: abord terapeutic s COPD Exacerbation – Exacerbation COPD Hospitalisation 28% • More Smoker as in EU • Quitters less as in EU

Smoking Fuma ţi Fuma ţi Priza ţi You tried Have Alt Withou cigarette ţig ări pe pip ă sau to you răspuns t s from care le sau mesteca ţi renounce ever (spontan) answer packs face ţi trabuc tutun smoke singur RO 31% 0 - - 11% 57% 0 15% Are you smoking at home?

RO: 91% yes

Second place in EU after Hungary

Compliance to guidelines?

COPD- WHAT IS PRESCRIBED IN EUROPE? GREAT BRITAIN ITA LIE BETA ADREN. 40% • METILXANTINS -40% INHAL CORTICOIDS 20% • ANTIB.AND ANTICOUGH- ANTICOLINERG. < 20% 25% 70% from the whole • BETA 2 ADRENERGICS < 20% prescription

GERMANY, AUSTRIA

• ANTICOUGH SI MUCOLITICS 35% • METILXANTINE 20%

M. Rudolf: The Reality of Drug Use in COPD. The European Perspective Chest 2000;117;29-32 COPD- WHAT IS PRESCRIBED IN ROMANIA ?

QUESTIONNAIRE FOR GP, PNEUMOLOGIST,

INTERNISTS IN 1998

(308 PATIENTS)

WHAT THEY PREFER AS TREATMENT

FOR COPD ?

V. Golli, Ileana Băzăvan, Andreea-Loredana Golli - Sondaj asupra măsurilor preconizate în BPOC. Pneumoftiziologia 1998, vol. XLVII, nr. 2, 83-88 WHAT MEDICATION IS PRESCRIBED IN ROMANIA - 1998?

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

V. Golli, Ileana Băzăvan, Andreea-Loredana Golli - Sondaj asupra măsurilor preconizate în BPOC. Pneumoftiziologia 1998, vol. XLVII, nr. 2, 83-88 WHAT ARE THE PRESCRIPTIONS IN THE HOSPITAL -2004

Simpatomimetice cu acţiune scurtă 83%

Teofiline orale (retard) 81%

Antibiotice 73%

Corticoizi inhalatori 72%

Fluidifiante de mucus 66%

Corticoizi sistemici 64%

Corticoizi oral 42%

Corticoizi parenteral 39%

Anticolinergice 30%

Simpatomimetice cu acţiune lungă 16%

Teofiline i.v. 6% 4% Antitusive

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

Irina Strambu: “BPOC – Astm bronsic: abord terapeutic s i costuri in Romania”, 2006, Teza de doctorat, UMF “Carol Davila”, Bucurest i EXACERBATIONS

AND COSTS OF COPD

IN ROMANIA Year Country COSTS Source

1154 ₤ (2300$)/PATIENT/year 1996 UK 47,5% Drugs 24% Oxyg. 18% Hospital National Health Service Executive. Burdens of disease: a discussion document. Leeds, United Kingdom; Department of 10% GM Health, 1996

Rutten-Van Mo¨ lken MP et al. Current and future medi cal cost 1999 HOLAND 813$/PATIENT of asthma and chronic obstructive pulmonary disease in the Netherlands. Respiratory Medicine, 1999, 93 (11): 779–787.

1876 €/PATIENT 2003 SPAIN 43% Hospital 40% Drugs Miravitlles M, Murio C, Guerrero T, Gisbert R. - Costs of chronic 15% Diagnosis Tests bronchitis and COPD: a 1-year follow-up study. Chest. 2003 Mar;123(3):784-91.

4366 €/PATIENT 41% MONITORING 2004 FRANCE 25% COMPLICATION Scope study - B. Detournay, C. Pribil, M. Fournier, B. Housset, 34% COMORBIDITIES G. Huchon, D. Huas, P. Godard, C. Voinet, I. Chanal, Colette Jourdanne, I. Durand-Zaleski, the SCOPE Group - The SCOPE 1/3 Hospital Study: Health-Care Consumption Related to Patients with 1/3 DRUGS Chronic Obstructive Pulmonary Disease in France. Value in Health Volume 7 Issue 2 Page 168 - March 2004 ROMANIA - COPD – 2004 - HOSPITALIZATION

25000 22912 BPOC 18714 20000 TOTAL: 75093 MALE: 49936 16434

15000 11892

10000

3064 5000 134 179 151 239 523 851

0 <1 1-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 >85

Source: Centrul de Statistica Medicala si Documentare Medicala Registrul National de boli pulmonare cronice 2005,fara numar pagina HEALTH CARE COSTS OF EACH OF THE ABOVE 4 SMOKING RELATED DISEASES BY AGE AND SEX-PER PATIENT ROMANIA - 2004

1576.3 1600 1530.2

1550

1500

1450

1400 1337.7 1336.1

1350

1300

1250

1200 Cancer Boli cerebro- BPOC Cardiopatii bronhopulmonar vasculare ischemice

Source: Centrul de Calcul si Statistica Sanitara –Bucuresti Anuar de Statistica Sanitara 2005, Cheltuieli sanitare, pag.263 COPD DRUGS – SALES-UNITS – ROMANIA 2006

VENTOLIN INHALER 704114

SYMBICORT 12083

12345 SPIRIVA

SINGULAIR 155558

SEREVENT 7261

SERETIDE 293448

FLIXOTIDE 34669

EURESPAL 856840

BECOTIDE+BECLOFORTE 111461 4884336

ALL XANTHINES

0 500000 1000000 1500000 2000000 2500000 3000000 3500000 4000000 4500000 5000000 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 s i costuri in Romania”, 2006, Teza de doctorat, UMF “Carol Davila”, Bucurest i 2004 COPD EXACERBATION – HOSPITALISATION

OVER 75% ARE SMOKERS

FEMALE 27,5%

72,5% MALE

Irina Strambu: “BPOC – Astm bronsic: abord terapeutic s i costuri in Romania”, 2006, Teza de doctorat, UMF “Carol Davila”, Bucurest i 2004 COPD EXACERBATION – HOSPITALISATION

Distributed by urban or rural areal

RURAL URBAN 48% 52%

Irina Strambu: “BPOC – Astm bronsic: abord terapeutic s i costuri in Romania”, 2006, Teza de doctorat, UMF “Carol Davila”, Bucurest i 2004 COPD EXACERBATION – HOSPITALISATION

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

Irina Strambu: “BPOC – Astm bronsic: abord terapeutic s i costuri in Romania”, 2006, Teza de doctorat, UMF “Carol Davila”, Bucurest i 2004 COPD EXACERBATION – HOSPITALISATION

Duration of hospitalisation

25 ZILE DE SPITALIZARE 21,12

17,18 20 15,84 15,6 14,94

0 STADIUL I STADIUL II STADIUL III STADIUL IV MEDIA

STAGE I-III Similar stay period STAGE IV Long period of hospitalization

Irina Strambu: “BPOC – Astm bronsic: abord terapeutic s i costuri in Romania”, 2006, Teza de doctorat, UMF “Carol Davila”, Bucurest i HEALTH CARE COSTS OF EACH OF THE ABOVE 4 SMOKING RELATED DISEASES BY AGE AND SEX ROMANIA – 2004-Average of hospitalisation days

Media zilelor de spitalizare

9.91 10 9.62

9.5

9 8.41 8.4 8.5

7.5 Cancer Boli cerebro- BPOC Cardiopatii bronhopulmonar vasculare ischemice

Source: Centrul de Calcul si Statistica Sanitara –Bucuresti Anuar de Statistica Sanitara 2005, Cheltuieli sanitare, pag.263 2004 AVERAGE 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 DAYS EVEN TO PATIENTS WITH EASY STAGING – WHY?

Irina Strambu: “BPOC – Astm bronsic: abord terapeutic s i costuri in Romania”, 2006, Teza de doctorat, UMF “Carol Davila”, Bucurest i 2004 COPD EXACERBATION – HOSPITALISATION Staging of the patients

45%

40%

35%

30%

25%

20%

15%

10%

5% 6% 24% 28% 42%

0% STADIUL I STADIUL II STADIUL III STADIUL IV

BLOOD GAS ANALYSES - 37% RESPIRATORY FAILURE Irina Strambu: “BPOC – Astm bronsic: abord terapeutic s i costuri in Romania”, 2006, Teza de doctorat, UMF “Carol Davila”, Bucurest i MOST PART OF HOSPITALIZED PATIENTS ARE IN STAGE III AND IV

“THE OTHERS” “ARE CARRING ” THE DISEASE UNDIAGNOSED

200

180

160

140

120

100

60 40 70% 20

0 181 PACIENTI STADII III+IV

Irina Strambu: “BPOC – Astm bronsic: abord terapeutic s i costuri in Romania”, 2006, Teza de doctorat, UMF “Carol Davila”, Bucurest i 2004 COPD EXACERBATION – HOSPITALIZED

CO-MORBIDITIES

45%

40%

35%

30%

25%

20%

15%

10%

5% 43% 16% 21% 20% 0% CARDIOVASCULAR DIABET ZAHARAT SECHELE TBC BROSIECTAZII

Irina Strambu: “BPOC – Astm bronsic: abord terapeutic s i costuri in Romania”, 2006, Teza de doctorat, UMF “Carol Davila”, Bucurest i 2004 COPD EXACERBATION – HOSPITALIZED

DIRECT COSTS – LABS INVESTIGATIONS

• MINIM AL – SIMPLE SPIROMETRY

• MAXIMAL – SEVERE PATIENT - ICU

REPETEATED MONITORING BLOOD GAS ANALYSIS

UNTIL 72 BLOOD GAS ANALYSIS / PATIENT

Irina Strambu: “BPOC – Astm bronsic: abord terapeutic s i costuri in Romania”, 2006, Teza de doctorat, UMF “Carol Davila”, Bucurest i COPD EXACERBATION – HOSPITALIZED

DIRECT COSTS – LAB INVESTIGATIONS

(RON) 5519 6000

5000

4000 2769.5

3000

2000

1000 20

0 MINIM MAXIM MEDIE

Irina Strambu: “BPOC – Astm bronsic: abord terapeutic s i costuri in Romania”, 2006, Teza de doctorat, UMF “Carol Davila”, Bucurest i 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 2004 COPD EXACERBATION – HOSPITALIZED DRUG COSTS

800 BPOC TOTAL

700 703,4

600

500

400 431

363,8 300

200 235,4 174,4 100 369,6 724,7 443,5 180,8 245,9

0 STADIUL I STADIUL II STADIUL III STADIUL IV MEDIE

DRUGS FOR COPD DRUGS FOR OTHER COMORBIDITIES

Irina Strambu: “BPOC – Astm bronsic: abord terapeutic s i costuri in Romania”, 2006, Teza de doctorat, UMF “Carol Davila”, Bucurest i COSTS OF DRUGS

PROGRESIVE OF THE COST IN THE SAME TIME WITH THE WORSENING OF THE DISEASE

TOTAL COSTS OF THE DRUGS EXCLUSIVELY THROUGH SPECIFIC DRUGS FOR COPD

SOFISTICATED ANTIBIOTICS

PARENTERAL CORTICOIDS

ANTITROMBOTICS “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 s i costuri in Romania”, 2006, Teza de doctorat, UMF “Carol Davila”, Bucurest i 2004 COPD EXACERBATION – HOSPITALIZED

Average costs per different stages

1200 EURO

1000

800

600

400

200 470 531 550 1129 727

0 STADIUL I STADIUL II STADIUL III STADIUL IV MEDIA

Irina Strambu: “BPOC – Astm bronsic: abord terapeutic s i costuri in Romania”, 2006, Teza de doctorat, UMF “Carol Davila”, Bucurest i TOTAL COSTS PER PATIENTS DISTRIBUTED BY STAGING

40000

35000

30000 investigations 25000 mii lei 20000 treatment

15000 loging

10000 total 5000

0 std I std II std III std IV COSTS OF TREATMENT IS <1/3 FROM THE TOTAL!

Irina Strambu: “BPOC – Astm bronsic: abord terapeutic s i costuri in Romania”, 2006, Teza de doctorat, UMF “Carol Davila”, Bucurest i PRESCRIPTION OF DRUGS FOR COPD (IN HOSPITAL)

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 2004 COPD EXACERBATION – HOSPITALIZED

THE REST OF 30%

ONLY WITH THE BASIC TREATMENT

WITH THE HOPE THAT

THE PATIENT WILL CONTINUE

THE THERAPY IN AMBULATORY PRESCRIPTION OF DRUGS FOR COPD (IN HOSPITAL)

PARENTERAL TEOPHYLINE VERY LOW

USED IN THE HOSPITAL

THEY PREFFERED SHORT ACTING

INHALER BRONCHODILATATOR

IN THE ACUTE BRONCHOSPASM

THERAPY IN AMBULATORY PRESCRIPTION BEFORE HOSPITALISATION IN AMBULATORY

BRONHODILATATOARE CU ACTIUNE 78% SCURTA

AMINOFILINA 45%

TEOFILINE RETARD 45%

BRONHODILATATOARE DE LUNGA 43% DURATA + CORTICOIZI INHALATORI

38% VACIN ANTIGRIPAL

ANTICOLINERGICE ASOCIAT ALTOR 23% BRONHODILATATOARE

CORTICOTERAPIE SISTEMICA 16%

8% ANTIBIOTICOTERAPIE PROFILACTICA

0% 10% 20% 30% 40% 50% 60% 70% 80%

Irina Strambu: “BPOC – Astm bronsic: abord terapeutic s i costuri in Romania”, 2006, Teza de doctorat, UMF “Carol Davila”, Bucurest i 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 ?

ONLY 36% OF THE DOCTORS

ARE MONITORING REGULARY

THEIR PATIENTS

V. Golli, Ileana Băzăvan, Andreea-Loredana Golli - Sondaj asupra măsurilor preconizate în BPOC. Pneumoftiziologia 1998, vol. XLVII, nr. 2, 83-88 REIMBURSEMENT OF THE COPD

TREATMENT IN ROMANIA COPD exacerbation INCOMES OF THE HOSPITALIZED PATIENTS

38 40 38

34 35

25 19 18 20 nr. pacienti 15 12

10 7 5 5 2 1

0 0 0,5 1 1,5 2 2,5 3 3,5 5,5 ? milioane lei lunar

MAJORITY OVER 80% - INCOMES < 200 RON/MONTH 11% WITHOUT ANY KIND OF INCOMES !

Irina Strambu: “BPOC – Astm bronsic: abord terapeutic s i costuri in Romania”, 2006, Teza de doctorat, UMF “Carol Davila”, Bucurest i MAJORITY 80% - INCOMES < 60 €/MONTH

11% WITHOUT INCOMES !

POSIBILITY TO RECEIVED A CORRECT CHRONIC THERAPY?

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 CONCLUSIONS

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 FUTURE DEMANDS 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 HOW WE CAN SOLVED THE PROBLEM

REIMBURSEMENT OF THE DRUGS

STUDIES OF EVALUATION COSTS-EFFICACY

MONITORING COPD-LOW COSTS

DEVELOPING THE AMBULATORY MONITORING

SYSTEM

AVOIDING HOSPITALIZATION 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