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
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
15
10
5
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
8
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
80
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
30
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?
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 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