Social economic costs of COPD in Extremadura (Spain): an observational study

Figures & data

Figure 1 Phases in data collection.

Abbreviations: CRF-R, researcher’s case report forms; CRF-P, patient’s case report forms; SGRQ-C, St George’s Respiratory Questionnaire for COPD; EQ-5D-5L, EuroQol-5D-5L questionnaire.

Table 1 Sociodemographic characteristics of the sample

Sociodemographic characteristics	Total
Gender (% males)	76.2
Age in years (mean ± SD)	71.8±10.3
Age group (%)
<65 years	20.7
≥65 years	79.3
Smoking history (%)
Current smoker	16.7
Ex-smoker	69.6
Never smoked	13.7
Daily cigarettes (mean ± SD)
Smokers	14.1±10.3
Ex-smoker	27.3±16.4
Education level (%)
Does not know how to read or write	6.0
No education	33.9
Primary education	35.9
Secondary education	18.5
University education	5.7
Employment status (%)
Early retirement/retired	78.9
Actively working	7.9
Domestic work	7.1
Unemployed	3.4
Permanent leave	1.6
Temporary leave	1.1

Abbreviation: SD, standard deviation.

Table 2 Clinical characteristics of the sample

Clinical characteristics	Total
FEV1/FVC (mean ± SD)a	60.3±18.7
FEV1 % (mean ± SD)b	66.7±22.3
COPD severity (%)
GOLD I	10.9
GOLD II	20.5
GOLD III	9.1
GOLD IV	1.3
Unknown/not available	58.3
Exacerbations in the last 12 months (% yes)c	36.7
Number of exacerbations in the last 12 months (mean ± SD)d	0.6±1.2
Number of comorbidities (mean ± SD)	7.8±4.7
Main comorbidities (%)
Cardiovascular comorbiditye	60.6
Dyslipidemia/lipid metabolism disorder	41.5
Noncomplicated hypertension	38.3
Diabetes mellitus (type 1 + type 2)	27.2
Arthritis/arthrosis	20.0
Cancer/malignancy	14.8
Hypertension with target organ involvement	13.0
Anemia	6.7
Depression	6.2
Asthma	6.0
Osteoporosis	3.9
BMI (mean ± SD)f	30.0±5.0
BMI classification according to WHO (%)
Insufficient weight	0.8
Normal weight	3.4
Overweight	16.1
Obesity	18.4
Unknown/not available	61.4

Notes:

a Number of valid cases: 123, number of missing values: 263.

b Number of valid cases: 140, number of missing values: 246.

c,d Number of valid cases: 215, number of missing values: 171.

e Includes cerebrovascular accident/ictus/apoplexy, unspecified cardiac arrhythmia, atherosclerosis or peripheral arterial disease, valvular heart disease, atrial fibrillation/atrial flutter, acute myocardial infarction, heart failure, cardiac ischemia with angina, cardiac ischemia without angina, transient cerebral ischemia, other cardiac diseases, other cardiovascular diseases, other cardiovascular signs/symptoms, and paroxysmal tachycardia.

f Number of valid cases: 149, number of missing values: 237.

Abbreviations: SD, standard deviation; BMI, body mass index; WHO, World Health Organization; FEV₁, forced expiratory volume in 1 second; FVC, forced vital capacity; COPD, chronic obstructive pulmonary disease; GOLD, Global Initiative for Chronic Obstructive Lung Disease.

Table 3 Utilization of health care resources in the last 12 months

Resource typology	Total	N (valid cases)a
Medical tests (mean ± SD)
Blood analysis	0.6±1.4	292
Spirometry with bd test	0.1±0.4	280
Spirometry without bd test	0.3±0.6	271
Alpha-1 antitrypsin	0.0±0.2	254
Chest X-ray	0.6±1.0	299
CAT	0.1±0.3	289
Gasometry	0.5±1.2	276
Pulmonology visits (mean ± SD)	0.8±1.3	386
Visits to the emergency room (mean ± SD)
Health center emergencies	0.3±0.7	284
Hospital emergencies	0.4±1.0	302
Use of ambulance (mean ± SD)
Total times	0.30±1.1	381
Times when used as non-assisted emergency health transportb	0.28±1.1	381
Use of home oxygen therapy (%)	15.4	386
Use of home oxygen therapy (only users) (mean ±	SD)c
Hours per day	14.5±5.7	57
Months (over the past year)	10.6±3.2	57
Hospital admissions (mean ± SD)	0.2±0.5	328
Medication consumed (%)		386
R01 nasal preparations	2.7
ICS	2.7
R03 agents against obstructive respiratory diseases	91.5
Short-acting beta agonists	6.2
Long-acting beta agonists	6.9
Short-acting muscarinic agonists	3.3
Long-acting muscarinic receptor antagonists	32.0
ICS	2.9
Fixed combinations	31.7
Leukotriene receptor antagonist	3.8
Interleukin inhibitors phosphodiesterase	3.4
Methylxanthines	1.4
R06 antihistamines for systemic use	5.8
Antihistamines for systemic use	5.8

Notes:

a Valid cases refer to all cases (386), including users of “zero” units, minus missing values.

b As opposed to on-site ambulance services.

c Results calculated only for users of home oxygen therapy (59 patients).

Abbreviations: bd, bronchodilator; SD, standard deviation; CAT, computerized axial tomography; ICS, inhaled corticosteroid.

Table 4 Utilization of non-health care resources in the last 12 months

Resource typology	Total (%/mean ± SD)	N (valid cases)a
Permanent stay in housing or residential center
Yes	3.8	386
Due to COPD	21.9
Attendance at day center
Yes	0.3	372
Due to COPD	0.0
Professional care at home
Due to COPD	5.3	371
Months over the past year (only users)b	10.8±3.1	18
Hours of weekly care (only users)b	12.7±16.1
Informal caregiving
Due to COPD	17.5	371
Months over the past year (only users)c	11.0±2.7
Hours of care per month
Principal caregiverd	19.0±53.0	386
Other caregivers	2.5±21.9
Number of informal caregiversc
One caregiver	63.4	63
Two or more caregivers	36.6
Profile of principal informal caregiverc
Gender
Female	84.3	64
Male	15.7
Age (years)	61.3±14.2
Relationship with the patient
Spouse/partner	44.8
Daughter/son	44.5
Other	10.7

Notes:

a Valid cases refer to all cases (386) minus missing values.

b Results calculated only for users of professional care at home (20 patients).

c Results calculated only for users of informal caregiving (65 patients).

d Censored to a maximum of 8 hours per day.

Abbreviations: SD, standard deviation; COPD, chronic obstructive pulmonary disease.

Table 5 Annual average costs per patient (euros 2015)

Cost typology	Mean ± SD	95% CI	% of subcategory	% of TC
Direct health costs	1,645±2,240	1,421–1,869	100	43.8
Medical testsa	47±121		2.9	1.2
Pulmonology visits	89±157		5.4	2.4
Emergency visitsb	102±439		6.2	2.7
Use of ambulanceb	108±433		6.6	2.9
Use of home oxygen therapyc	187±459		11.3	5.0
Hospital admissions	380±1.387		23.1	10.1
Medication (total)	732±626		44.5	19.5
R01 nasal preparations
ICS	5±20		0.3	0.1
R03 agents against obstructive respiratory diseases
Short-acting beta agonists	367±407		22.3	9.8
Long-acting beta agonists	13±51		0.8	0.3
Short-acting muscarinic agonists	49±142		3.0	1.3
Long-acting muscarinic receptor antagonists	236±258		14.4	6.3
ICS	13±56		0.8	0.3
Fixed combinations	1±6		0.1	0.0
Leukotriene receptor antagonist	28±133		1.7	0.7
Interleukin inhibitors phosphodiesterase	5±15		0.3	0.1
Methylxanthines	6±27		0.3	0.1
R06 antihistamines for systemic use
Antihistamines for systemic use	9±29		0.6	0.2
Direct non-health costs	1,440±4,068	1,033–1,847	100	38.3
Stay in residential center	73±797		5.0	1.9
Attendance at day center	0.0±0.0		0.0	0.0
Formal care in home	189±1.287		13.1	5.0
Informal care	1,179±3,749		81.9	31.4
Principal caregiverd	1,036±3,051		71.9	27.6
Other caregivers	143±1,333		10.0	3.8
Indirect coste	672±3,744	298–1,047	100	17.9
Total cost/patient/year	3,757±6,800	3,077–4,438	–	100

Notes: All costs have been rounded to the nearest unit.

a Zero cost (0 euros) has been assigned to patients without available information; the cost of additional tests specified in the CRF-R is included.

b Zero cost (0 euros) has been assigned to patients without available information.

c The cost has been calculated assuming the use of full months of oxygen therapy; in cases without information on the months of use, the average time of use of the rest of the patients has been assigned.

d Cost calculated assuming 8 hours a day of informal care.

e All cases were included: zero cost (0 euros) has been assigned to patients >65 years of age (age of retirement) and to labor productivity losses that were not a consequence of COPD.

Abbreviations: SD, standard deviation; CI, confidence interval; ICS, inhaled corticosteroid; COPD, chronic obstructive pulmonary disease; CRF-R, researcher’s case report forms. gender, and age group (euros 2015)

Table 6 Average annual costs per patient according to severity, gender, and age group (euros 2015)

Subgroups	Valid N	DHC	DNHC	IC	TC
GOLD severity scale
GOLD I	41	1,246*	1,004	550	2,800*
GOLD II	79	2,123*	1,042	1,120	4,285*
GOLD III	35	2,430*	3,507*	1,905	7,842*
GOLD IVa	5	5,669*	7,691*	4,298	17,658*
Unknownb	226	1,334	1,189	261	2,784
Gender
Male	308	1,682	1,456	678	3,816
Female	78	1,500	1,376	649	3,525
Age range
<65 years	80	1,261*	560*	2,650*	4,471*
≥65 years	306	1,745*	1,670*	157c,*	3,571*
Total	386	1,645	1,440	672	3,757

Notes: All costs have been rounded to the nearest unit.

a The low number of valid cases in this category suggests caution in the interpretation of its results.

b This category was not included in the analysis of differences (Kruskal–Wallis test).

c Corresponds to labor productivity losses in the last 12 months for people up to 65 years of age.

* Statistically significant differences (p<0.05) within each type of cost between the categories of each variable.

Abbreviations: DHC, direct health costs; DNHC, direct non-health costs; IC, indirect costs; TC, total cost; GOLD, Global Initiative for Chronic Obstructive Lung Disease.

Figure 2 Total annual cost of COPD in Extremadura in 2015 according to cost typology.

Abbreviation: COPD, chronic obstructive pulmonary disease.

Table S1 Unit prices of resources related to COPD

Resources	Euros (2015)	Reference
Visits to the pulmonology specialist
First visit
Section 1	201.82	Section 1: HA of Badajoz^Citation1
Section 2	183.57	Section 2: HA of Cáceres^Citation1
Section 3	145.69	Section 3: HA of Don Benito-Villanueva, Mérida, Llerena-Zafra, and Plasencia^Citation1
Section 4	131.13	Section 4: HA of Navalmoral and Coria^Citation1
Subsequent visit
Section 1	121.09	Section 1: HA of Badajoz^Citation1
Section 2	110.15	Section 2: HA of Cáceres^Citation1
Section 3	87.42	Section 3: HA of Don Benito-Villanueva, Mérida, Llerena-Zafra, and Plasencia^Citation1
Section 4	78.68	Section 4: HA of Navalmoral and Coria^Citation1
Medical tests
Blood analysis	72.45	^Citation1
Spirometry with bd test	84.16	^Citation1
Spirometry without bd test	42.08	^Citation1
Alpha-1 antitrypsin	10.29	Average price ^Citation2–Citation4
Chest X-ray	17.08	^Citation1
CAT	93.97	^Citation1
Gasometry	7.88	^Citation1
Other medical tests
Ag1 Legionella urine	21.03	^Citation1
Antibiogram	37.58	^Citation1
Diffusing capacity	133.17	^Citation1
Co-oximetry	11.60	^Citation5
Sputum culture	37.58	^Citation1
Streptococcus pneumoniae culture	23.20	^Citation1
6-minute walk test	126.66	^Citation1
Electrocardiogram	30.24	^Citation1
Echocardiogram	168.83	^Citation1
Abdominal ultrasound	54.79	^Citation1
FeNO	17.19	^Citation2
Pulmonary scintigraphy	272.49	^Citation1
Thyroid hormones	26.12	^Citation1
Cardiorespiratory polygraphy	192.79	Average price ^Citation2,Citation4,Citation6,Citation7
Oxygen saturation/pulsometry	2.81	^Citation4,Citation5
Visits to the emergency room
Emergency consultation in primary care	54.88	^Citation1
Emergency consultation in hospital care	218.61	^Citation1
Use of ambulance
Use of non-assisted emergency health transport	273.23	Average price ^Citation4,Citation5,Citation8–Citation15
Use of emergency ambulance (medicalized) in situ	1,076.46	^Citation1
Hospital admissions
GRD 85: pleural effusion with CC	4,533.10	^Citation16
GRD 88: COPD	2,652.45	^Citation16
GRD 89: simple pneumonia and pleuritis age >17 with CC	3,581.46	^Citation16
GRD 99: respiratory signs and symptoms with CC	3,221.03	^Citation16
GRD 101: other respiratory system diagnoses with CC	3,495.95	^Citation16
GRD 143: chest pain	2,338.61	^Citation16
Home oxygen therapy
One day of use	3.74	Weighted average according to percentage of use of each type of home oxygen therapy^Citation17
Stay in housing or residential center
One month of stay in nursing home	732.91	^Citation1
Day care center
Care/year/user	6,145.35	^Citation18
Professional care at home
One hour of formal care	6.14	^Citation18
Informal care
One hour of informal care	5.08	Equivalent to 1 hour of minimum interprofessional salary for domestic employees, as it is not specialized care^Citation19
Wage for every hour worked
Females
Occupation high	16.88	Large occupation groups 1–3^Citation20,Citation21
Occupation medium	9.90	Large occupation groups 4–7^Citation20,Citation21
Occupation low	9.38	Large occupation groups 8 and 9^Citation20,Citation21
All occupations	11.81	^Citation20,Citation21
Males
Occupation high	20.05	Large occupation groups 1–3^Citation20,Citation21
Occupation medium	11.45	Large occupation groups 4–7^Citation20,Citation21
Occupation low	9.67	Large occupation groups 8 and 9^Citation20,Citation21
All occupations	13.39	^Citation20,Citation21

Abbreviations: HA, health area; bd, bronchodilator; CC, complications and/or comorbidities; FeNO, fractional exhaled nitric oxide; GRD, related groups by diagnosis; Ref, reference; CAT, computerized axial tomography.

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