Indirect costs in chronic obstructive pulmonary disease: A review of the economic burden on employers and individuals in the United States

Figures & data

Table 1 Studies included in the review

Author and publication year	Data year(s)	Study design and data source	Primary study population	Age of study population	Category of outcomes assesseda
Strassels et al, 2001^Citation13	1987	Cross-sectional design using National Medical Expenditure Survey data	Persons with COPD	≥40 years	Absenteeism/work loss, restricted activity days, bed confinement days
Ward et al, 2002^Citation8	1993–1994	Cross-sectional design using SIPP and National Health Interview Survey data	Persons with self-reported COPD	≥25 years	Workforce participation, work limitation, absenteeism/work loss
Sin et al, 2002^Citation10	1994	Cross-sectional design using NHANES III data	Persons with COPD based on spirometry	18–64 years	Workforce participation, per person indirect costs, total US costs
Leigh et al, 2002^Citation16	1996	Population-based cost estimates using cost inputs obtained from national surveys	Estimated US population with occupational COPDb	≥35 years	Productivity loss, morbidity and mortality costs; per person indirect costs, total US costs
Mannino et al, 2002^Citation9	1996	Cross-sectional study using NHIS data	Adults	Not provided	Workforce participation, activity limitation, absenteeism/work loss, restricted activity days, bed confinement days
Goetzel et al, 2003^Citation17	1997–1999	Retrospective analysis of claims data using Marketscan HPM Database (data from six large employers)	Persons with COPD based on claims data; n=374,799	≥18 years	Employer costs for productivity loss and disability
Halpern et al, 2003^Citation11	2000	Cross-sectional study using the US subsample of the Confronting COPD survey	Persons with physician-diagnosed COPD	≥45 years	Work limitation, absenteeism/work loss, per person productivity loss costs
Nair et al, 2012^Citation14	2000–2007	Retrospective case-control analysis of claims data using Thomas Reuters Marketscan Commercial Claims Database and Health and Productivity (HPM) Database	Employed adults with COPD based on claims data and matched controls; n=27,612	18–65 years	Absenteeism/work loss, short-term disability, per person indirect costs, employer costs
Darkow et al, 2007^Citation15	2001–2004	Case-control study (matched 1:2) using claims from nine multi-state employers	1,349 cases with primary diagnosis of COPD; 2,696 controls	40–63 years	Long-term disability, per person indirect costs
Wang et al, 2003^Citation5	Not stated	Cross-sectional analysis using World Health Organization’s Health and Work Performance Questionnaire	Persons with self-reported COPD	≥18 years	Disability prevalence, absenteeism/work loss, presenteeism
DiBonaventura et al, 2012^Citation12	2009	Cross-sectional analysis using self-reported data from the 2009 National Health and Wellness Survey	Employed older adults with and without self-reported COPD	≥65 years	Activity limitation, absenteeism/work loss, presenteeism, short-term disability

Notes:

a See Tables 2, 3, and 4 for more specific outcome measures

b COPD due to occupational exposure to harmful substances, such as dust and gases.

Abbreviations: COPD, chronic obstructive pulmonary disease; NHANES III, National Health and Examination Survey III; NHIS, National Health Interview Survey; SIPP, Survey of Income and Program Participation (US Census Bureau).

Table 2 Proportion of individuals with COPD reporting productivity impairment: ability to work, work and activity limitations, and disability

Study	Data year(s)	Prevalence
		Proportion participating in workforce
		Able to work/working
Sin et al, 2002^Citation10	1988–1994	69.21% (COPD group)a 77.24% (no COPD group) (P for difference = 0.001)
Ward et al, 2002^Citation8	1993–1994	81.6%b (chronic bronchitis group) 37.1%b (emphysema group) 65%b,c (any COPD)
Mannino et al, 2002^Citation9	1996	56% (COPD group) 54% (COPD + asthma group) 65% (no COPD/no asthma group) Unable to work due to COPD
Ward et al, 2002^Citation8	1993–1994	0.6% (chronic bronchitis group) 27.4% (emphysema group) 14%a (any COPD)
Halpern et al, 2003^Citation11	2000	34% (persons with COPD)
		Proportion with work limitations
Ward et al^Citation8	1993–1994	11.6% (chronic bronchitis group) 16.3% (emphysema group) 13%a (any COPD)
Halpern et al^Citation11	2000	18% (persons with COPD)
		Proportion with activity limitations
Mannino et al, 2002^Citation9	1996	32% (COPD, no asthma group) 45% (COPD + asthma group)
DiBonaventura et al, 2012^Citation12	2009	29.6% (COPD group) 13.9% (no COPD group)
		Proportion with disability
		Short-term disability claim	Long-term disability claim
Darkow et al, 2007^Citation15	2001–2004	21.8% (COPD cases) 7% (controls)	2.4% (COPD cases) 0.4% (controls)

Notes:

a In a logistic regression model that adjusted for age, sex, education, smoking status and other variables, having mild, moderate or severe COPD was associated with a 3.4%, 3.9%, and 14.4% reduction in the workforce participation rate, respectively (P<0.001 for linear trend)

b the study publication presents results as the proportion of the sample unable to work/not working as follows: 18.4% (chronic bronchitis), 62.9% (emphysema), 35% (chronic bronchitis or emphysema). We have subtracted these proportions from 1 to report the inverse value (proportion able to work/working) in order to facilitate comparison across studies

c Values for the combined chronic bronchitis and emphysema groups were calculated by the authors using data provided in the publication.

Abbreviation: COPD, chronic obstructive pulmonary disease.

Table 3 Days per year: work loss, disability, and bed confinement in persons with COPD

Study	Base year	Mean days per yeara (patient subgroup)
		Absenteeism/work loss days
Strassels et al, 2001^Citation13	1987	1.0 COPD-related (COPD group) 3.6 all cause (COPD group)
Ward et al, 2002^Citation8	1993–1994	1.5 (chronic bronchitis group) 1.3 (emphysema group)
Mannino et al, 2002^Citation9	1996	2.4 (COPD group) 8.2 (COPD + asthma group) 2.9 (no COPD/no asthma group)
Halpern et al, 2003^Citation11	2000	18.7b (COPD group) 1.7 (caregivers)
Nair et al, 2012^Citation14	2000–2007	0.3 hours/month, COPD-related (COPD group) 5.6 hours/month, all cause (COPD group) 3.8 hours/month, all cause (no COPD group)
DiBonaventura et al, 2012^Citation12	2009	1.88 hours in past 7 days (COPD group) 0.77 hours in past 7 days (no COPD group)
Wang et al, 2003^Citation5	Not stated	19.4b,c (persons with COPD)
		Presenteeism days
Wang et al, 2003^Citation5	Not stated	27.5c (persons with COPD)
DiBonaventura et al, 2012^Citation12	2009	4.82 hours in past 7 days (COPD group) 2.59 hours in past 7 days (no COPD group)
		Short-term disability days
Darkow et al, 2007^Citation15	2001–2004	54.8 (COPD cases) 39.1 (controls)
Nair et al, 2012^Citation14	2000–2007	0.3 days/month, COPD-related (COPD group) 1.0 days/month, all cause (COPD group) 0.6 days/month, all cause (no COPD group)
		Long-term disability days
Darkow et al, 2007^Citation15	2001–2004	76.4 (COPD group) 85.9 (controls)
		Restricted activity days
Strassels et al, 2001^Citation13	1987	15.9 COPD-related 27.5 all cause
Mannino, 2002^Citation9	1996	31.0 (COPD group) 62.5 (COPD + asthma group) 15.3 (no COPD/no asthma group)
		Bed confinement days
Strassels et al, 2001^Citation13	1987	16.1 COPD-related (COPD group) 24.4 all cause (COPD group)
Mannino, 2002^Citation9	1996	13.1 (COPD group) 31.5 (COPD + asthma group) 6.1 (no COPD/no asthma)

Notes:

a Except as otherwise noted

b includes vacation days

c value represents excess days due to COPD.

Abbreviation: COPD, chronic obstructive pulmonary disease.

Table 4 Costs associated with the indirect burden of COPD

Study	Base year	Outcome measure	Reported cost	Cost inflated to 2010 USDa
Mean cost per person affected by the condition of interest
Nair et al, 2012^Citation14	2000–2007	Mean annual indirect expenditures	$909 (case) versus $3,609 (control)	$1,016 (case) versus $4,032 (control)
Darkow et al, 2007^Citation15	2001–2004	Mean annual all-cause disability cost per case (COPD) or control with disability claim	$9,815 (case) versus $6,335 (control)	$14,130 (case) versus $9,121 (control)
Mean cost per person for total COPD population
Leigh et al, 2002^Citation16	1996	Mean annual mortality (lost productivity) costs for occupational COPD	$526b	$896
		Mean annual morbidity costs for occupational COPD	$376b	$640
		Total mean indirect costs for occupational COPD	$893b	$1,521
Halpern et al, 2003^Citation11	2000	Mean annual indirect costs	$1,527	$2,289
Darkow et al, 2007^Citation15	2001–2004	Mean annual disability costs	$2,234b	$3,348
Employer cost per employeec
Goetzel et al, 2003^Citation17	1997–1999	Mean annual COPD-related absence payment	$22.62	$37.22
		Mean annual COPD-related short-term disability payment	$5.21	$8.57
Nair et al, 2012^Citation14	2000–2007	Mean annual COPD-related absence payment	$55	$61
		Mean annual COPD-related disability payment	$527	$589

Notes:

a Inflated using medical care component of the Consumer Price Index

b calculated by authors using data provided in publication

c denominator is all employees. COPD prevalence in this employed population was 3.5%.

Abbreviations: COPD, chronic obstructive pulmonary disease; USD, US dollars.

Figure 1 Study attrition diagram.

Abbreviation: COPD, chronic obstructive pulmonary disease

Table 5 Estimates of the annual indirect costs of COPD in the US

Study	Base year	Indirect cost measure	Study result	Value in 2010 USDa
Sin et al, 2002^Citation10	1988–1994	Productivity loss	$9.9 billion	$18.5 billion
Leigh et al, 2003^Citation16	1999	Lost earnings	$1.57 billion	$2.44 billion
		Lost fringe benefits	$0.36 billion	$0.56 billion
		Lost home earningsb	$0.21 billion	$0.33 billion
		Total lost earnings and fringe benefits	$2.14 billion	$3.321 billion
Leigh et al, 2003^Citation16	1999	Morbidity	$1.26 billion	$1.957 billion
		Mortality	$0.88 billion	$1.374 billion
		Total morbidity and mortality	$2.14 billion	$3.321 billion
NHLBI, 2009^Citation6	Various	Projected 2010 morbidityc	$8.0 billion	$8.0 billion
NHLBI, 2012^Citation1		2008 premature mortalityc	$14.8 billion	$15.0 billion

Notes:

a Study values were inflated to USD 2010 value using medical care component of the Consumer Price Index

b lost productivity related to home tasks such as child care, home repair, meal preparation, etc

c included for comparative purposes.

Abbreviations: COPD, chronic obstructive pulmonary disease; NHLBI, National Heart, Lung and Blood Institute; USD, US dollars.

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