burden of copd in romania - who.int last.pdf · bronhopulmonar boli cerebro-vasculare bpoc...

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

Duţu St, Păun G. – Prevalenţa simptomelor respiratorii, a astmului bronşic şi bronşitei cronice (simple şi obstructive) într-un eşantion reprezentativ de populaţie adultă rurală. Pneumoftiziologia 1998, Jul-Sep, 47(3): 151-160.

4,60%2,30%

MALE

FEMALE

COPD PREVALENCE IN ROMANIA

IN 1998

ROMANIA - COPD INCIDENCE – 2004 - GP MISSDIAGNOSIS

21485

6

12821

4918

0

5000

10000

15000

20000

25000

To t al 0 - 14 15- 6 4 ≥6 5

Source: Centrul de Statistica Medicala si Documentare MedicalaRegistrul National de boli pulmonare cronice 2005,fara numar pagina

27212

0

16860

10352

0

5000

10000

15000

20000

25000

30000

Tot al 0 - 14 15- 6 4 ≥6 5


ROMANIA - COPD INCIDENCE – 2004 - SPECIALISTS DIAGNOSIS-also internal medicin -

Duţu St, Păun G. – Prevalenţa simptomelor respiratorii, a astmului bronşic şi bronşitei cronice (simple şi obstructive) într-un eşantion reprezentativ de populaţie adultă rurală. Pneumoftiziologia 1998, Jul-Sep, 47(3): 151-160.

ROMANIA – MORTALITY RATE

Chronic Obstructive Diseases - 1998

5,00%OOO

20,00%OOO

MALE

FEMALE

RISK FACTORS

SMOKING HABITS

Irina Strambu: “BPOC – Astm bronsic: abord terapeutic si costuri in Romania”, 2006, Teza de doctorat, UMF “Carol Davila”, Bucuresti

ROMANIA 2006

COPD Exacerbation – Hospitalisation

Smoking Habits of the patients

21%

39%

28%

12%

Unsmokers

Ex/smokers

Smokers

Not mention

Average of 20 package / year

• More Smoker as in EU

• Quitters less as in EU

15%057%11%--031%RO

Without answer

Alt răspuns (spontan)

Have you ever smoke

You tried to renounce

Prizaţi sau mestecaţi tutun

Fumaţi pipă sau trabuc

Fumaţi ţigări pe care le faceţi singur

Smoking cigarettes from packs

Are you smoking at home?

RO: 91% yes

Second place in EU

after Hungary

Compliance to guidelines?

COPD- WHAT IS PRESCRIBED IN

EUROPE?

M. Rudolf: The Reality of Drug Use in COPD. The European Perspective Chest 2000;117;29-32

GREAT BRITAIN

BETA ADREN. 40%

INHAL CORTICOIDS 20%

ANTICOLINERG. < 20%

70% from the whole

prescription

GERMANY, AUSTRIA

• ANTICOUGH SI MUCOLITICS 35%

• METILXANTINE 20%

ITALIE

• METILXANTINS -40%

• ANTIB.AND ANTICOUGH-25%

• BETA 2 ADRENERGICS < 20%

COPD- WHAT IS PRESCRIBED IN ROMANIA ?

V. Golli, Ileana Băzăvan, Andreea-Loredana Golli - Sondaj asupra măsurilor preconizate în BPOC.

Pneumoftiziologia 1998, vol. XLVII, nr. 2, 83-88

QUESTIONNAIRE FOR GP, PNEUMOLOGIST,

INTERNISTS IN 1998

(308 PATIENTS)

WHAT THEY PREFER AS TREATMENT

FOR COPD ?

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

4%

6%

16%

30%

39%

42%

64%

66%

72%

73%

81%

83%

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

Antitusive

Teofiline i.v.

Simpatomimetice cu acţiune lungă

Anticolinergice

Corticoizi parenteral

Corticoizi oral

Corticoizi sistemici

Fluidifiante de mucus

Corticoizi inhalatori

Antibiotice

Teofiline orale (retard)

Simpatomimetice cu acţiune scurtă

WHAT ARE THE PRESCRIPTIONS IN THE HOSPITAL -2004


EXACERBATIONS

AND COSTS OF COPD

IN ROMANIA

FRANCE

SPAIN

HOLAND

UK

Country

Scope study - B. Detournay, C. Pribil, M. Fournier, B. Housset, G. Huchon, D. Huas, P. Godard, C. Voinet, I. Chanal, Colette Jourdanne, I. Durand-Zaleski, the SCOPE Group - The SCOPE Study: Health-Care Consumption Related to Patients with Chronic Obstructive Pulmonary Disease in France. Value in

Health Volume 7 Issue 2 Page 168 - March 2004

4366 €/PATIENT

41% MONITORING

25% COMPLICATION

34% COMORBIDITIES

1/3 Hospital

1/3 DRUGS

2004

Miravitlles M, Murio C, Guerrero T, Gisbert R. - Costs of chronic bronchitis and COPD: a 1-year follow-up study. Chest. 2003

Mar;123(3):784-91.

1876 €/PATIENT

43% Hospital

40% Drugs

15% Diagnosis Tests

2003

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

813$/PATIENT1999

National Health Service Executive. Burdens of disease: a discussion document. Leeds, United Kingdom; Department of

Health, 1996

1154 ₤(2300$)/PATIENT/year

47,5% Drugs

24% Oxyg.

18% Hospital

10% GM

1996

SourceCOSTSYear


134 179 151 239 523

3064

18714

16434

22912

11892

851

0

5000

10000

15000

20000

25000

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

BPOCTOTAL: 75093MALE: 49936

ROMANIA - COPD – 2004 - HOSPITALIZATION

HEALTH CARE COSTS OF EACH OF THE ABOVE 4 SMOKING RELATED DISEASES BY AGE AND SEX-PER PATIENT

ROMANIA - 2004

Source: Centrul de Calcul si Statistica Sanitara –BucurestiAnuar de Statistica Sanitara 2005, Cheltuieli sanitare, pag.263

1337.7

1576.3

1530.2

1336.1

1200

1250

1300

1350

1400

1450

1500

1550

1600

Cancer

bronhopulmonar

Boli cerebro-

vasculare

BPOC Cardiopatii

ischemice

COPD DRUGS – SALES-UNITS – ROMANIA 2006

4884336111461

856840

34669

293448

7261

155558

12345

12083

704114

0 500000 1000000 1500000 2000000 2500000 3000000 3500000 4000000 4500000 5000000

ALL XANTHINES

BECOTIDE+BECLOFORTE

EURESPAL

FLIXOTIDE

SERETIDE

SEREVENT

SINGULAIR

SPIRIVA

SYMBICORT

VENTOLIN INHALER

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”


27,5%

72,5%

FEMALE

MALE

2004

COPD EXACERBATION – HOSPITALISATION

OVER 75% ARE SMOKERS


2004COPD EXACERBATION – HOSPITALISATION

Distributed by urban or rural areal

52%48%URBANRURAL


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

2004



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

Duration of hospitalisation

15,6 15,8414,94

21,12

17,18

0

5

10

15

20

25

STADIUL I STADIUL II STADIUL III STADIUL IV MEDIA

ZILE DE SPITALIZARE

2004



HEALTH CARE COSTS OF EACH OF THE ABOVE 4 SMOKING RELATED DISEASES BY AGE AND SEX

ROMANIA – 2004-Average of hospitalisation days

Source: Centrul de Calcul si Statistica Sanitara –BucurestiAnuar de Statistica Sanitara 2005, Cheltuieli sanitare, pag.263

8.41

9.919.62

8.4

7.5

8

8.5

9

9.5

10

Cancer

bronhopulmonar

Boli cerebro-

vasculare

BPOC Cardiopatii

ischemice

Media zilelor de spitalizare

2004AVERAGE 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 DAYSEVEN TO PATIENTS WITH EASY STAGING – WHY?


BLOOD GAS ANALYSES - 37% RESPIRATORY FAILURE

6% 24% 28% 42%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

STADIUL I STADIUL II STADIUL III STADIUL IV

Staging of the patients

2004



MOST PART OF HOSPITALIZED PATIENTS

ARE IN STAGE III AND IV

“THE OTHERS” “ARE CARRING ” THE DISEASE UNDIAGNOSED

0

20

40

60

80

100

120

140

160

180

200

181 PACIENTI STADII III+IV

70%


CO-MORBIDITIES

43% 16% 21% 20%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

CARDIOVASCULAR DIABET ZAHARAT SECHELE TBC BROSIECTAZII

2004

COPD EXACERBATION – HOSPITALIZED


DIRECT COSTS – LABS INVESTIGATIONS

• MINIMAL – SIMPLE SPIROMETRY

• MAXIMAL – SEVERE PATIENT - ICU

REPETEATED MONITORING BLOOD GAS ANALYSIS

UNTIL 72 BLOOD GAS ANALYSIS / PATIENT

2004



DIRECT COSTS – LAB INVESTIGATIONS

20

5519

2769.5

0

1000

2000

3000

4000

5000

6000

MINIM MAXIM MEDIE

(RON)



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

DRUG COSTS

DRUGS FOR COPD

DRUGS FOR OTHER COMORBIDITIES

174,4

180,8

235,4

245,9

363,8

369,6

703,4

724,7

431

443,5

0

100

200

300

400

500

600

700

800

STADIUL I STADIUL II STADIUL III STADIUL IV MEDIE

BPOC TOTAL

2004



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

� TOTAL COSTS OF THE DRUGSEXCLUSIVELY THROUGH �� SPECIFIC DRUGS

FOR COPD

SOFISTICATED ANTIBIOTICS

PARENTERAL CORTICOIDS

ANTITROMBOTICS

COSTS OF DRUGS

“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.


Average costs per different stages

470 531 550 1129 727

0

200

400

600

800

1000

1200

STADIUL I STADIUL II STADIUL III STADIUL IV MEDIA

EURO

2004



TOTAL COSTS PER PATIENTS

DISTRIBUTED BY STAGING

0

5000

10000

15000

20000

25000

30000

35000

40000

mii lei

std I std II std III std IV

investigations

treatment

loging

total

COSTS OF TREATMENT IS

<1/3 FROM THE TOTAL!


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

PRESCRIPTION OF DRUGS FOR COPD

(IN HOSPITAL)

THE REST OF 30%

ONLY WITH THE BASIC TREATMENT

WITH THE HOPE THAT

THE PATIENT WILL CONTINUE

THE THERAPY IN AMBULATORY

2004


PARENTERAL TEOPHYLINE VERY LOW

USED IN THE HOSPITAL

THEY PREFFERED SHORT ACTING

INHALER BRONCHODILATATOR

IN THE ACUTE BRONCHOSPASM

PRESCRIPTION OF DRUGS FOR COPD(IN HOSPITAL)

THERAPY

IN AMBULATORY

PRESCRIPTION BEFORE HOSPITALISATION IN AMBULATORY

8%

16%

23%

38%

43%

45%

45%

78%

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

ANTIBIOTICOTERAPIE PROFILACTICA

CORTICOTERAPIE SISTEMICA

ANTICOLINERGICE ASOCIAT ALTOR

BRONHODILATATOARE

VACIN ANTIGRIPAL

BRONHODILATATOARE DE LUNGA

DURATA + CORTICOIZI INHALATORI

TEOFILINE RETARD

AMINOFILINA

BRONHODILATATOARE CU ACTIUNE

SCURTA


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

REIMBURSEMENT OF THE COPD

TREATMENT IN ROMANIA

COPD exacerbation

INCOMES OF THE HOSPITALIZED PATIENTS

MAJORITY OVER 80% - INCOMES < 200 RON/MONTH

11% WITHOUT ANY KIND OF INCOMES !

1819

34

38 38

5

7

21

12

0

5

10

15

20

25

30

35

40

nr.

pacie

nti

0 0,5 1 1,5 2 2,5 3 3,5 5,5 ?

milioane lei lunar


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

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

CONCLUSIONS

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

FUTURE DEMANDS

REIMBURSEMENT OF THE DRUGS

STUDIES OF EVALUATION COSTS-EFFICACY

MONITORING COPD-LOW COSTS

DEVELOPING THE AMBULATORY MONITORING

SYSTEM

AVOIDING HOSPITALIZATION

HOW WE CAN SOLVED THE PROBLEM

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

burden of copd in romania - who.int last.pdf · bronhopulmonar boli cerebro-vasculare bpoc...

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