COPD: Consequences of an Underrecognized Disease

Chronic obstructive pulmonary disease generates huge costs in the working population, yet it is given scant attention. Here are the facts and the actions employers can take.

By Hemal Shah, PharmD and Bob Nordyke, PhD

How is it that a disease that costs over $30 billion annually, results in 58 million annual lost workdays and is the fourth leading cause of death in the U.S. can still be unfamiliar to most people? Chronic obstructive pulmonary disease (COPD) is only slowly being recognized, though it exacts a substantial toll on patients, the U.S. workforce and the U.S. healthcare system. In fact, the Institute of Medicine considers COPD to be one of the major diseases that threaten the financial stability of our health care system.¹ Understanding the consequences of this underrecognized disease can help employers identify opportunities to improve care and put an infrastructure in place to help manage costs.

What is COPD?

COPD is characterized by obstruction of the airways leading to airflow limitation.² It includes chronic bronchitis and emphysema, with common symptoms of chronic cough and shortness of breath. COPD differs from other lung diseases because the airway obstruction is not fully reversible — even with medications — and the disease gets progressively worse over time. COPD is also often marked by bouts of worsening symptoms called exacerbations that are responsible for increased absenteeism and a greater use of health care resources, such as hospitalizations.

Despite basic differences between the diseases, asthma and COPD are often confused in practice. Up to 17 percent of adults who have been diagnosed as asthmatics may actually have COPD.³ Misdiagnosis has important implications for patient care since the treatment of asthma and COPD are quite distinct.^2,4 If not properly diagnosed and treated, the symptoms of COPD can become debilitating and even more costly.

What are the symptoms?

COPD patients experience shortness of breath, chronic cough and chronic production of phlegm. They have to work harder to breathe, which leads to fatigue and other symptoms that can limit a person’s ability to perform usual daily activities, such as climbing a flight of stairs. Chronic cough is normally the first symptom to develop, but most COPD sufferers first go to a physician because of shortness of breath.² By that time, symptoms are often severe, and the condition has progressed beyond its earliest stages, when treatments should be initiated. Making problems worse, even when sufferers go to their physicians, under-diagnosis of COPD is quite common.⁵ This is unfortunate since a variety of treatments can alleviate symptoms, reduce disability and help decrease overall costs of care.²

What causes COPD?

Cigarette smoking is the leading cause of COPD.⁶ About 15 percent of all smokers have COPD severe enough to cause symptoms, and this percentage increases with age. Smoking cessation can dramatically slow the progression of COPD.^7,8

Smoking, however, is not the only cause. Prolonged exposure to environmental and industrial air pollution — even the use of wood stoves at home — are important causes of COPD.^9-15 Occupations associated with the highest risk of developing COPD include mining, farming, metal working, textile dyeing and manufacturing.^10-13 The combined effects of a high-risk occupation and smoking leads to an even greater risk of COPD.¹¹

The consequences of COPD

COPD causes considerable disability, with approximately 45 percent of COPD patients having a restricted activity level.¹⁶ Among individuals over 40 years of age, COPD ranks second only to coronary disease as a cause of disability. Another measure of the burden COPD places on society is the disability-adjusted life year (DALY). The DALY for a specific condition represents the sum of years lost because of premature mortality and years of life lived with disability, adjusted for the severity of disability. The World Bank Global Burden of Disease Study projected that in 2020 COPD will account for 4.1 percent of total DALYs and rank fifth in lost DALYs behind ischemic heart disease, major depression, traffic accidents and cerebrovascular disease. ¹⁷

Additionally, COPD ranks behind only cardiovascular diseases and cancer as a leading cause of deaths in the U.S. Examining trends in death rates over time, the rise of COPD is startling. While mortality from cardiovascular diseases and cancer has declined over the last 30 years, COPD deaths are increasing, as shown in the figure below.

Source: Global Initiative for Chronic Obstructive Lung Disease, 2001¹⁸

COPD has been stereotyped as a disease of the elderly and male population, but it is also present in women, has a major impact on the working-age population¹⁹ and is more common than asthma or diabetes in people 45-64 years old.²⁰ Only one-third to one-half of adults in the U.S. who have COPD have been diagnosed with COPD by their physicians.²¹ These undiagnosed people may have a large impact on future health care costs since they are not receiving proper advice and treatment to slow the progression of COPD and alleviate the symptoms that lead to disability.

The impact on employers

COPD has a direct impact on the cost of employee benefits. It costs the U.S. an estimated $32.1 billion annually (in 2002 dollars).²² Hospitalizations and emergency room care account for over half of the total direct medical costs for COPD.^22,23 Worse, these costs are recurrent. Nearly one-half of patients hospitalized for COPD are hospitalized an average of 1.7 more times within the next six months.²⁴

COPD indirect costs affect the day-to-day cost of business. Symptoms of COPD result in productivity losses, absenteeism and disability. About 8 percent of individuals with chronic bronchitis and 70 percent of individuals with emphysema report that their respiratory condition limits the work they can do.²⁵ Some COPD patients eventually become unable to work because of their disease. The decreased ability to function that results from COPD doubles the chance of job loss compared to that of the average adult. Compared to asthma, lost work due to COPD is 3.5 to 6.8 times higher.^26,27

Lost wages due to COPD are estimated at about $10 billion annually. This estimate does not account for other sources of lost productivity such as a reduced ability to perform while on the job, and retraining costs.²⁸ In addition to lost workdays, COPD patients suffer from lower quality of life. Decreased ability to function physically and socially can impair a person’s ability to perform on the job. Thus, from an employer’s perspective, COPD has a major impact on the cost of daily operations.

Putting the overall economic impact of COPD into context, the following figure shows that the costs of COPD are greater than those of other major respiratory diseases as well as many non-respiratory chronic diseases that often receive more attention than COPD.

Sources: Sullivan 2000;²⁹ NIH 2000;³⁰ Brown et al. 1995;³¹ Sonnenber 1997³²

Opportunities to improve care: The role of employers

There are several actions that employers can take in collaboration with their health plan providers to accurately diagnose and effectively treat employees with COPD. These types of programs have the potential to impact work productivity and absenteeism while improving health outcomes and reducing costs. Employers can check with their health plan providers regarding specific programs that the health plan has in place to optimize COPD health care.

• Improving Diagnosis: How does the health plan ensure that employees with an unrecognized disease are properly diagnosed? Getting proper care for undiagnosed COPD sufferers will have a major impact on future costs. Diagnosis of COPD during early stages of the disease is critical for smoking cessation to have its maximum effect in slowing the progression of COPD.

• Improving Treatment: How does the health plan ensure that employees are receiving recommended treatments? Optimal care for those already diagnosed can result in substantial improvements in symptoms and quality of life, as well as reductions in medical expenses.¹⁵ In clinical studies, treatment of COPD with recommended medications (i.e., bronchodilators to open up the airways) has been shown to be effective in improving physical functioning and quality of life.² Moreover, use of appropriate medical therapies can reduce total medical costs by 26 to 42 percent.^33,34

Employers can also sponsor disease management programs. These are new programs that emphasize human interaction with evidence-based approaches that improve outcomes and reduce costs. Such strategies are gaining momentum; implementation of employer-sponsored disease management programs tripled from 2001 to 2002.³⁵

• Over 6,000 COPD patients from a variety of commercial and Medicare health plans participated in a COPD management program focused on both patient and physician interventions. Results showed significant improvements in symptoms and physical functioning. There was also a decrease of 5.4 percent in total medical costs net of program costs.³⁶

• In another COPD disease management program, trained nurse case managers provided education and compliance support to individuals with COPD and communication with their physicians. Hospitalizations, emergency room visits, ICU admissions, unscheduled office visits and the need for antibiotics all significantly decreased in one year. Days missed from work also were significantly reduced.³⁷

Employers can offer programs to assist their employees with COPD. These programs can help employees take an active part in managing their health.

• Prevention at the Worksite: Smoke-free work environments and careful adherence to occupational safety procedures (e.g., use of breathing equipment in selected industries) can reduce exposure to environmental pollutants that increase the risk of COPD or worsen symptoms for those who have COPD.

• Education: Campaigns to increase employee awareness of COPD symptoms (e.g., shortness of breath is not a "normal" part of getting older and should be brought to the attention of a physician), and the impact of smoking can improve early detection of COPD.

• COPD Screening: Programs to encourage lung function testing for those at high risk for COPD will improve early detection.

• Patient Programs: Smoking cessation programs can help reduce incidence of COPD. Once an employee has been diagnosed with COPD, one-on-one case-management programs can be effective. Patients in such programs receive counseling from trained health care professionals on self-care practices, especially the importance of compliance with prescribed treatments; how to use inhaled medications; and how to track and manage symptoms.³⁶

Together, these components of effective COPD management can help control the impact of COPD that, without efforts to improve prevention and quality of care, will surely continue to escalate into the foreseeable future.

Hemal Shah is Director of Health Economics at Boehringer Ingelheim Pharmaceuticals, Inc (BIPI). Prior to her position at BIPI, she completed a fellowship in Outcomes Research at Novartis Pharmaceuticals/PennState Geisinger Health Plan and worked as consultant at Pharmacon International conducting health economics and outcomes research studies. Hemal received her Doctor of Pharmacy degree from Rutgers University and received B.S. degrees in Pharmacy and Molecular Biology from University of Connecticut. Robert Nordyke is Senior Research Associate at Zynx Health in the Health Economics Research group. He is also an Adjunct Assistant Professor at the UCLA School of Public Health. Robert received his PhD. from the RAND Graduate School. He can be reached by e-mail at bnordyke@cerner.com .

More Business & Health Articles About This Topic:

Why We Can't Wait to Implement Disease Management (October 15, 2003)

Disease Management Comes of Age, Not a Moment too Soon (June 19, 2002)

Breathing Lessons: The Costs of COPD (October 1996)

Resource Links:

National Heart, Lung, and Blood Institutehttp://www.nhlbi.nih.gov/resources/docs/02_chtbk.pdf

American Thoracic Societywww.thoracic.org

Disease Management Association of Americahttp://www.dmaa.org

Global Initiative for Chronic Obstructive Lung Diseasehttp://www.goldcopd.com/

American Lung Associationhttp://www.lungusa.org

References:

¹ Institute of Medicine. Crossing the quality chasm: a new health system for the 21^st century. Washington DC: National Academy Press, 2001.

² Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease: NHLBI/WHO Workshop Report. 2003 Update. Available at URL: www.goldcopd.com

³ Marklund B, Tunsater A, Bengtsson C. How often is the diagnosis bronchial asthma correct? Fam Pract 1999;16:112-116.

⁴ American Thoracic Society. Standards for the diagnosis and care of patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1995;152(5 Pt 2):S77-S121.

⁵ den Otter JJ, van Dijk B, van Schayck CP, et al. How to avoid underdiagnosed asthma/chronic obstructive pulmonary disease? J Asthma. 1998;3:381-387.

⁶ Silverman EK Speizer FE. Risk factors for the development of chronic obstructive pulmonary disease. Med Clin North Am 1996;80:501-522.

⁷ Tashkin DP, Clark VA, Coulson AH, et al. The UCLA population studies of chronic obstructive respiratory disease, VIII. Effects of smoking cessation on lung function: a prospective study of a free-living population. Am Rev Respir Dis 1984;130:707-715.

⁸ Anthonisen NR, Connett JE, Kiley JP, et al. Effects of smoking intervention and the use of an inhaled anticholinergic bronchodilator on the rate of decline of FEV1. The Lung Health Study. JAMA 1994;272:1497-1505.

⁹ Zhang J, Smith KR. Hydrocarbon emissions and health risks from cookstoves in developing countries. J Expo Anal Environ Epidemiol 1996;6:147-161.

¹⁰ Bakke PS, Baste V, Hanoa R, Gulsvik A. Prevalence of obstructive lung disease in a general population: relation to title and exposure to some airborne agents. Thorax 1991;46:863-870.

¹¹ Oxman AD, Muir DC, Shannon HS, et al. Occupational dust exposure and chronic obstructive lung disease. A systematic review of the evidence. Am Rev Respir Dis 1993;148:38-48.

¹² Mengesha YA, Bekele A. Relative chronic effects of different occupational dusts on respiratory indices and health workers in three Ethiopian factories. Am J Ind Med 1998;34:373-380.

¹³ Zuskin E, Mustajbegovic J, Schacter EN, Doko-Jelinic J. Respiratory function of textile workers employed in dyeing cotton and wool fibers. Am J Ind Med 1997;31:344-352.

¹⁴ Melbostad E, Eduard W, Magnus P. Chronic bronchitis in farmers. Scan J Work Environ Health 1997;23:271-280.

¹⁵ Fishwick D, Bradshaw LM, D’Souza W, et al. Chronic bronchitis, shortness of breath, and airway obstruction by occupation in New Zealand. Am J Respir Crit Care Med 1997;156:1440-1446.

¹⁶ Ward MM, Javitz HS, Smith WM, Whan MA. Lost income and work limitations in persons with chronic respiratory disorders. J Clin Epidemiol 2002;55:260-8.

¹⁷ The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries and risk factors in 1990 and projected to 2020. Eds. Murray CJL, Lopez AD. The Global Burden of Disease and Injury Series: v.1. Cambridge, MA: Harvard University Press, 1996

¹⁸ Global Initiative for Chronic Obstructive Lung Disease. GOLD Teaching Slide Set. Available at URL: www.goldcopd.com . Accessed May, 2002.

¹⁹ Mannino DM, Gagnon RC, Petty TL, Lydick E. Obstructive lung disease and low lung function in adults in the United States: Data from the National Health and Nutrition Examination Survey, 1988-1994. Arch Intern Med 2000 Jun;160:1683-9.

²⁰ Adams PF, Hendershot GE, Marano MA. Current estimates from the National Health Interview Survey, 1996. National Center for Health Statistics. Vital Health Stat 10(200). 1999.

²¹ Petty TL. Definitions, causes, course, and prognosis of chronic obstructive pulmonary disease. Respir Care Clin N Am 1998;4:345-358.

²² National Heart, Lung, and Blood Institute. Morbidity and Mortality: 2002 Chart Book on Cardiovascular, Lung, and Blood Diseases. National Institutes of Health, National Heart, Lung, and Blood Institute; May 2002. Available at: http://www.nhlbi.nih.gov/resources/docs/02_chtbk.pdf .

²³ Wilson L, Devine EB, So K. Direct medical costs of chronic obstructive pulmonary disease: Chronic bronchitis and emphysema. Resp Med. 2000; 94:204-213.

²⁴ Connors AF, Dawson NV, Thomas C, et al. Outcomes following acute exacerbation of severe chronic obstructive lung disease. Am J Respir Crit Care Med 1996;154(4 Pt 1):959-67.

²⁵ Ward MM, Javitz HS, Smith WM, Whan MA. Lost income and work limitations in persons with chronic respiratory disorders. J Clin Epidem 2002; 55:260-268.

²⁶ Weiss KB, Sullivan SD. The health economics of asthma and rhinitis. I. Assessing the economic impact. J Allergy Clin Immunology 2001; 107(1):3-8.

²⁷ Leigh JP, Romano PS, Schenker MB, Kreiss K. Costs of occupational COPD and asthma. Chest 2002; 121:264-272.

²⁸ Pauly MV, Nicholson S, Xu J, et al. A general model of the impact of absenteeism on employers and employees. Health Economics. 2002;11:221-231.

²⁹ Sullivan SD, Ramsey SD, Lee TA. The economic burden of COPD. Chest. 2000;117:5S-9S.

³⁰ National Institutes for Health, Office of the Director. Disease-specific estimates of direct and indirect costs of illness and NIH support: Fiscal year 2000 update. DHHS, NIH, Office of the Director, Washington: National Institutes of Health; 2000.

³¹ Brown ML, Fintor L The economic burden of cancer. In: Greenwald P Kramer BS Weed DL eds. Cancer Prevention and Control NY: Marcek Dekker, Inc. 1995, pp. 69-81. Cited in: National Institutes for Health, Office of the Director. Disease-specific estimates of direct and indirect costs of illness and NIH support: Fiscal year 2000 update. DHHS, NIH, Office of the Director, Washington: National Institutes of Health; 2000.

³² Sonnenberg A, Everhart JE. Health impact of peptic ulcer in the United States. Am J Gastroenterol. 1997;92(4):614-20. Cited in: National Institutes for Health, Office of the Director. Disease-specific estimates of direct and indirect costs of illness and NIH support: Fiscal year 2000 update. DHHS, NIH, Office of the Director, Washington: National Institutes of Health; 2000.

³³ Friedman M, Serby CW, Menjoge SS, et al. Pharmacoeconomic evaluation of a combination of ipratropium plus albuterol compared with ipratropium alone and albuterol alone in COPD. Chest 1999;115:635-641.

³⁴ Friedman M, Hilleman DE. Economic burden of chronic obstructive pulmonary disease. Impact of new

treatment options. Pharmacoeconomics 2001;19:245-54.

³⁵ Watson Wyatt Worldwide. New rules for managing health costs: Highlights from the Seventh Annual Washington Business Group on Health /Watson Wyatt Survey. Available online at: www.watsonwyatt.com . Accessed April, 2002.

³⁶ Zajac B. Measuring outcomes of a chronic obstructive pulmonary disease management program. Disease Mgt 2002;5:9-19.

³⁷ Tinkelman D, Corsello P, McClure D, Yin M. One year outcomes from a disease management program for chronic obstructive pulmonary disease. Dis Manage Health Outcomes 2003;11:49-59.

Hemal Shah, Bob Nordyke. COPD: Consequences of an Underrecognized Disease.

Business and Health

Feb. 13, 2004;22.