COPD: Economical and Surrogate Outcomes—The Case of COPD

  • Roberto W. Dal Negro
  • Claudio F. DonnerEmail author


We will discuss the overall economics in pulmonary rehabilitation by taking chronic obstructive pulmonary disease (COPD) as a model because it is the most prevalent and incident chronic respiratory pathology [1, 2] in both western and developing countries [3] which is provided by a large and consolidated literature. What is available specifically for pulmonary rehabilitation will be addressed in a devoted sub-section. In general, all countries, even those characterized by evolved health models, took their first operational steps quite recently in the field of the “respiratory chronicity”, and of COPD in particular.


  1. 1.
    Murray CJ, Lopez AD. Alternative projections of mortalità and disability by cause 1990–2020—Global Burden of Disease Study. Lancet. 1997;349:1498–504.CrossRefPubMedGoogle Scholar
  2. 2.
    Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease (Updated February 2013), 2013. Available from: Accessed December 10, 2014
  3. 3.
    Yack D, Hawkes C, Gould CL, Hofman KJ. The global Burden of chronic diseases. Overcoming impediments of prevention and control. JAMA. 2004;291(21)Google Scholar
  4. 4.
    Mathers CD, Loncar D. Projections of global mortality and Burden of disease from 2002 to 2030. PLoS Med. 2006;3(11):e442.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Mannino DM, Higuchi K, Yu TC, Zhou H, Li Y, Tian H, Suh K. Economic burden of chronic obstructive pulmonary disease by presence of comorbidities. Chest. 2015;147:1199–201.CrossRefPubMedGoogle Scholar
  6. 6.
    Donner CF, Virchow JC, Lusuardi M. Pharmacoeconomics in COPD and inappropriateness of diagnostics, management and treatment. Respir Med. 2011;105:828–37.CrossRefPubMedGoogle Scholar
  7. 7.
    Sullivan SD, Ramsey SD, Lee TA. The economic burden of COPD. Chest. 2000;117(Suppl. 2):5–9s.CrossRefGoogle Scholar
  8. 8.
    Sullivan SD, Buist AS, Weiss K. Health outcomes assessment and economic evaluation in COPD: challenges and opportunities. Eur Respir J Suppl. 2003;41:1–3s.CrossRefGoogle Scholar
  9. 9.
    Lee TA, Sullivan SD, Buist AS, Vollmer W, Weiss KB. Estimating the future burden of COPD; 2006; ATS Abstract Issue, vol. 3: A598.Google Scholar
  10. 10.
    National Heart, Lung, and Blood Institute. Morbidity and mortality: 2009 chart book on cardiovascular, lung, and blood diseases. accessed 18.01.2010.
  11. 11.
    Croxton TL, Bailey WC. Long-term oxygen treatment in chronic obstructive pulmonary disease: recommendations for future research: an NHLBI workshop report. Am J Respir Crit Care Med. 2006;174:373e8.CrossRefGoogle Scholar
  12. 12.
    Dal NR, Berto P, Tognella S, Quareni L. Cost-of-illness of lung disease in the TriVeneto Region, Italy: the GOLD study. Monaldi Arch Chest Dis. 2002;57:1–7.Google Scholar
  13. 13.
    Dal Negro RW, Tognella S, Tosatto R, Dionisi M, Turco P, Donner CF. Costs of chronic obstructive pulmonary disease (COPD) in Italy: the SIRIO study. Respir Med. 2008;102:92–101.CrossRefPubMedGoogle Scholar
  14. 14.
    Dal Negro RW, Bonadiman L, Turco P, Tognella S, Iannazzo S. Costs of illness analysis in Italian patients with chronic obstructive pulmonary disease (COPD): an update. Clinicoecon Outcomes Res. 2015;7:153–9.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Sculpher M. Using economic evaluations to reduce the burden of asthma and chronic obstructive pulmonary disease. Pharmacoeconomics. 2001;19(Suppl. 2):21–5.CrossRefPubMedGoogle Scholar
  16. 16.
    Ruchlin HS, Dasbach AJ. An economic overview of chronic obstructive pulmonary disease. Pharmacoeconomics. 2001;19:623–42.CrossRefPubMedGoogle Scholar
  17. 17.
    Rennard S, Decramer M, Calverley PMA, et al. Impact of COPD in North America and Europe in 2000: subjects’ perspective of Confronting COPD International Survey. Eur Respir J. 2002;20:799–805.CrossRefPubMedGoogle Scholar
  18. 18.
    Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med. 2006;3(11):e442.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    van Boven JF, Vegter S, van der Molen T, Postma MJ. COPD in the working age population: the economic impact on both patients and government. COPD. 2013;10:629–39.CrossRefPubMedGoogle Scholar
  20. 20.
    Grupo DAFNE- Direct costs to primary care of chronic bronchitis. Analysis of a prospective study. Aten Primaria. 2001;27:399–4.Google Scholar
  21. 21.
    Rutten van-Molken MP, Feenstra TL. The burden of asthma and chronic obstructive pulmonary disease: data from The Nederlands. Pharmacoeconomics. 2001;19 Suppl. 2:1–6.CrossRefPubMedGoogle Scholar
  22. 22.
    Shaya FT, Dongyi D, Akazawa MO, Blanchette CM, Wang J, Mapel DW, Dalal A, Scharf SM. Burden of concomitant asthma and COPD in a Medical population. Chest. 2008;134:14–9.CrossRefPubMedGoogle Scholar
  23. 23.
    Srivastava K, Thakur D, Sharma S, Punekar YS. Systematic review of humanistic and economic burden of symptomatic chronic obstructive pulmonary disease. Pharmacoeconomics. 2015;33:467–88.CrossRefPubMedGoogle Scholar
  24. 24.
    Shaya FT, Maneval MS, Gbarayor CM, Sohn K, Dalal A, Du D, Scharf SM. Burden of COPD, asthma, and concomitant COPD and asthma among adults: racial disparities in a medical population. Chest. 2009;136:405–11.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Shaya FT, Lin PJ, Aljiawadi MH, Scharf SM. Elevated economic burden in obstructive lung disease patients with concomitant sleep apnea syndrome. Sleep Breath. 2009;13:317–23.CrossRefPubMedGoogle Scholar
  26. 26.
    Patel JG, Nagar SP, Dala AA. Indirect costs in chronic obstructive pulmonary disease: e reiew of the economic burden on employers and individuals in the United states. Int J Chron Obstruct Pulmon Dis. 2014;19:289–300.CrossRefGoogle Scholar
  27. 27.
    Hilleman DE, Dewan N, Malesker M, Friedman M. Pharmacoeconomic evalutation of COPD. Chest. 2000;118:1278–85.CrossRefPubMedGoogle Scholar
  28. 28.
    Toy EL, Gallagher KF, Stanley EL, Swensen AR, Duh MS. The economic impact of exacerbations of chronic obstructive pulmonary disease and exacerbation definition: a review. COPD. 2010;7:214–28.CrossRefPubMedGoogle Scholar
  29. 29.
    Jahnz-Rozyk K, Targowski T, From S. Costs of exacerbations of chronic obstructive pulmonary disease in primary ans secondary care in 2007—results of a multicenter Polish study. Pol Menkur Lekarski. 2009;26:208–14.Google Scholar
  30. 30.
    Seemungal TA, Donaldson GC, Bhowmik A, Jeffries DJ, Wedzicha JA. Time course and recovery of exacerbations in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2000;161(5):1608–13.CrossRefPubMedGoogle Scholar
  31. 31.
    Soler-Cataluña JJ, Martínez-García MA, Román Sánchez P, Salcedo E, Navarro M, Ochando R. Severe acute exacerbations and mortality in patients with chronic obstructive pulmonary disease. Thorax. 2005;60(11):925–31.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Simoens S, Decramer M. Pharmacoeconomics of the management of acute exacerbations of chronic obstructive pulmonary disease. Expert Opin Pharmacother. 2007;8:633–48.CrossRefPubMedGoogle Scholar
  33. 33.
    Mapel DW, Schum M, Lydick E, MArton JP. A new method for examining the cost savings of reducing COPD exacerbations. Pharmacoeconomics. 2010;28:733–49.CrossRefPubMedGoogle Scholar
  34. 34.
    Dal Negro RW, Celli BR. The BODECOST Index (BCI): a composite index for assessing the impact of COPD in real life. Multidiscip Respir Med. 2016;11:10.CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Tantucci C, Modina D. Lung function decline in COPD. Int J ChronObstruct Pulmon Dis. 2012;7:95–9.CrossRefGoogle Scholar
  36. 36.
    Ramsey SD, Sullivan SD. Chronic obstructive pulmonary disease: is there a case for early intervention? Am J Med. 2004;117 Suppl 12A:3S–10S.PubMedGoogle Scholar
  37. 37.
    Zoia MC, Corsico AG, Beccaria M, Guarnone R, Cervio G, Testi R, Bressan MA, Pozzi E, Cerveri I. Exacerbations as a starting point of pro-active chronic obstructive pulmonary disease management. Respir Med. 2005;99(12):1568–75.CrossRefPubMedGoogle Scholar
  38. 38.
    Menn P, Leidl R, Holle R. A lifetime Markov model for the economic evaluation of chronic obstructive pulmonary disease. Pharmacoeconomics. 2012;30(9):825–40.CrossRefPubMedGoogle Scholar
  39. 39.
    Getsios D, Marton JP, Revankar N, Ward AJ, Willke RJ, Rublee D, Ishak KJ, Xenakis JG. Smoking cessation treatment and outcomes patterns simulation: a new framework for evaluating the potential health and economic impact of smoking cessation interventions. Pharmacoeconomics. 2013;31(9):767–80.CrossRefPubMedGoogle Scholar
  40. 40.
    Jiménez-Ruiz CA, Solano-Reina S, Signes-Costa J, de Higes-Martinez E, Granda-Orive JI, Lorza-Blasco JJ, Riesco-Miranda JA, Altet-Gomez N, Barrueco M, Oyagüez I, Rejas J, SESEPARAR’s Integrated Tobacco Research Program. Budgetary impact analysis on funding smoking-cessation drugs in patients with COPD in Spain. Int J Chron Obstruct Pulmon Dis. 2015;10:2027–36.PubMedPubMedCentralGoogle Scholar
  41. 41.
    Howard P, Knight C, Boler A, Baker C. Cost-utility analysis of varenicline versus existing smoking cessation strategies using the BENESCO Simulation model: application to a population of US adult smokers. Pharmacoeconomics. 2008;26(6):497–511.CrossRefPubMedGoogle Scholar
  42. 42.
    Lee KH, Phua J, Lim TK. Evaluating the pharmacoeconomic effect of adding tiotropium bromide to the management of chronic obstructive pulmonary disease patients in Singapore. Respir Med. 2006;100(12):2190–6.CrossRefPubMedGoogle Scholar
  43. 43.
    Zaniolo O, Iannazzo S, Pradelli L, Miravitlles M. Pharmacoeconomic evaluation of tiotropium bromide in the long-term treatment of chronic obstructive pulmonary disease (COPD) in Italy. Eur J Health Econ. 2012;13(1):71–80.CrossRefPubMedGoogle Scholar
  44. 44.
    Ferroni E, Belleudi V, Cascini S, Di Martino M, Kirchmayer U, Pistelli R, Patorno E, Formoso G, Fusco D, Perucci CA, Davoli M, Agabiti N, OUTPUL study group. Role of tiotropium in reducing exacerbations of chronic obstructive pulmonary disease when combined with long-acting Β2-agonists and inhaled corticosteroids: the OUTPUL Study. J Clin Pharmacol. 2016; doi:10.1002/jcph.750. [Epub ahead of print]
  45. 45.
    Halpin DM. Symbicort: a pharmacoeconomic review. J Med Econ. 2008;11:345–62.CrossRefPubMedGoogle Scholar
  46. 46.
    Najafzadeh M, Marra CA, Sadatsafavi M, Aaron SD, Sullivan SD, Vandemheen KL, Jones PW, Fitzgerald JM. Cost effectiveness of therapy with combinations of long acting bronchodilators and inhaled steroids for treatment of COPD. Thorax. 2008;63(11):962–7.CrossRefPubMedGoogle Scholar
  47. 47.
    Dal Negro R, Bonadiman L, Tognella S, Micheletto C, Turco P. The impact of LABA+ICS fixed combinations on morbidity and economic burden of COPD in Italy: a six-year observational study. Ther Adv Respir Dis. 2011;5(2):83–90.CrossRefPubMedGoogle Scholar
  48. 48.
    Simoens S, Decramer M. A pharmacoeconomic review of the management of respiratory tract infections with moxafloxacin. Expert Opin Pharmacother. 2008;9:1735–44.CrossRefPubMedGoogle Scholar
  49. 49.
    Simoens S, Laekeman G, Decramer M. Preventing COPD exacerbations with macrolids; a review and budget impact analysis. Respir Med. 2013;107:637–48.CrossRefPubMedGoogle Scholar
  50. 50.
    Simoens S, Decramer M, Laekeman G. Economic aspects of antimicrobial therapy of acute exacerbations of COPD. Respir Med. 2007;101(1):15–26.CrossRefPubMedGoogle Scholar
  51. 51.
    Rutten-van Mölken MP, van Nooten FE, Lindemann M, Caeser M, Calverley PM. A 1-year prospective cost-effectiveness analysis of roflumilast for the treatment of patients with severe chronic obstructive pulmonary disease. Pharmacoeconomics. 2007;25(8):695–711.CrossRefPubMedGoogle Scholar
  52. 52.
    Moretti M, Bottrighi P, Dallari R, Da Porto R, Dolcetti A, Grandi P, Garuti G, Guffanti E, Roversi P, De Gugliemo M, Potena A, EQUALIFE Study Group. The effect of long-term treatment with erdosteine on chronic obstructive pulmonary disease: the EQUALIFE Study. Drugs Exp Clin Res. 2004;30(4):143–52.PubMedGoogle Scholar
  53. 53.
    Sclar DA, Evans MA, Robison LM, Skaer TL. α1-Proteinase inhibitor (human) in the treatment of hereditary emphysema secondary to α1-antitrypsin deficiency: number and costs of years of life gained. Clin Drug Investig. 2012;32(5):353–60.CrossRefPubMedGoogle Scholar
  54. 54.
    Słominski JM, Kubiak A. Pharmacoeconomics of vaccinations in chronic obstructive pulmonary disease. Pol Merkur Lekarski. 2004;16(Suppl 1):83–5.PubMedGoogle Scholar
  55. 55.
    Rodríguez González-Moro JM, Menéndez R, Campins M, Lwoff N, Oyagüez I, Echave M, Rejas J, Antoñanzas F. Cost effectiveness of the 13-valent pneumococcal conjugate vaccination program in chronic obstructive pulmonary disease patients aged 50+ years in Spain. Clin Drug Investig. 2016;36(1):41–53.CrossRefPubMedGoogle Scholar
  56. 56.
    Dal Negro RW. The tele-control at home. In: Dal Negro RW, Hodder R, editors. Long-term oxygen therapy. New insights & perspectives. Milan: Springer Verlag; 2012. p. 171–84.CrossRefGoogle Scholar
  57. 57.
    Restrepo RD, Alvarez MT, Wittnebel LD, Sorenson H, Wettstein R, Vines DL, Sikkema-Ortiz J, Gardner DD, Wilkins RL. Medication adherence issues in patients treated for COPD. Int J Chron Obstruct Pulmon Dis. 2008;3(3):371–84.CrossRefPubMedPubMedCentralGoogle Scholar
  58. 58.
    van Boven JF, Chavannes NH, van der Molen T, Rutten-van Mölken MP, Postma MJ, Vegter S. Clinical and economic impact of non-adherence in COPD: a systematic review. Respir Med. 2014;108(1):103–13.CrossRefPubMedGoogle Scholar
  59. 59.
    Virchow JC, Crompton GK, Dal Negro RW, Pedersen S, Magnan A, Seidemberg J, et al. Importance of inhaler devices in the management of airway diseases. Respir Med. 2008;102:10–9.CrossRefPubMedGoogle Scholar
  60. 60.
    van Boven JF, Tommelein E, Boussery K, Mehuys E, Vegter S, Brusselle GG, Rutten-van Mölken MP, Postma MJ. Improving inhaler adherence in patients with chronic obstructive pulmonary disease: a cost-effectiveness analysis. Respir Res. 2014;15:66. doi:10.1186/1465-9921-15-66.CrossRefPubMedPubMedCentralGoogle Scholar
  61. 61.
    Dal Negro RW, Povero M. The economic impact of educational training assessed by the Handling Questionnaire with three inhalation devices in asthma and Chronic Obstructive Pulmonary Disease patients. Clinicoeconomics Outcomes Res. 2016;8:171–6.Google Scholar
  62. 62.
    Spruit MA, Singh SJ, Garvey C, Zuwallack R, Nici L, Rochester C, Hill K, Holland AE, Lareau SC, Man WD, Pitta F, Sewell L, Raskin J, Bourbeau J, Crouch R, Franssen FM, Casaburi R, Vercoulen JH, Vogiatzis I, Gosselink R, Clini EM, Effing TW, Maltais F, van der Palen J, Troosters T, Janssen DJ, Collins E, Garcia-Aymerich J, Brooks D, Fahy BF, Puhan MA, Hoogendoorn M, Garrod R, Schols AM, Carlin B, Benzo R, Meek P, Morgan M, Rutten-van Mölken MP, Ries AL, Make B, Goldstein RS, Dowson CA, Brozek JL, Donner CF, Wouters EF, ATS/ERS Task Force on Pulmonary Rehabilitation. An official American Thoracic Society/European Respiratory Society statement: Key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med. 2013;188(8):e13–64. doi:10.1164/rccm.201309-1634ST.CrossRefPubMedGoogle Scholar
  63. 63.
    Rochester CL, Vogiatzis I, Holland AE, Lareau SC, Marciniuk DD, Puhan MA, Spruit MA, Masefield S, Casaburi R, Clini EM, Crouch R, Garcia-Aymerich J, Garvey C, Goldstein RS, Hill K, Morgan M, Nici L, Pitta F, Ries AL, Singh SJ, Troosters T, Wijkstra PJ, Yawn BP, RL ZW. ATS/ERS Task Force on Policy in Pulmonary Rehabilitation. Am J Respir Crit Care Med. 2015;192(11):1373–86.CrossRefPubMedGoogle Scholar
  64. 64.
    Goldstein RS, Gort EH, Guyatt GH, Feeny D. Economic analysis of respiratory rehabilitation. Chest. 1997;112:370–9.CrossRefPubMedGoogle Scholar
  65. 65.
    Jain VV, Allison R, Beck SJ, Jain R, Mills PK, McCurley JW, Van Gundy KP, Peterson MW. Impact of an integrated disease management program in reducing exacerbations in patients with severe asthma and COPD. Respir Med. 2014;108(12):1794–800.CrossRefPubMedGoogle Scholar
  66. 66.
    Burns DK, Wilson EC, Browne P, Olive S, Clark A, Galey P, Dix E, Woodhouse H, Robinson S, Wilson A. The cost effectiveness of maintenance schedules following pulmonary rehabilitation in patients with chronic obstructive pulmonary disease: an economic evaluation alongside a randomised controlled trial. Appl Health Econ Health Policy. 2016;14(1):105–15.CrossRefPubMedGoogle Scholar
  67. 67.
    Dritsaki M, Johnson-Warrington V, Mitchell K, Singh S, Rees K. An economic evaluation of a self-management programme of activity, coping and education for patients with chronic obstructive pulmonary disease. Chron Respir Dis. 2016;13(1):48–56.CrossRefPubMedGoogle Scholar
  68. 68.
    Howard-Wilsher S, Irvine L, Fan H, Shakespeare T, Suhrcke M, Horton S, Poland F, Hooper L, Song F. Systematic overview of economic evaluations of health-related rehabilitation. Disabil Health J. 2016;9(1):11–25.CrossRefPubMedGoogle Scholar
  69. 69.
    Prescott E, Lange P, Vestbo J. Socioeconomic status, lung function and admission to hospital for COPD: results from the Copenhagen City Health Study. Eur Respir J. 1999;13:1109–14.CrossRefPubMedGoogle Scholar
  70. 70.
    Thorn J, Bjorkelund C, Bengtsson C, Guo X, Lissenr L, Sundh V. Low socio-economic status, smoking, mental stress and obesity predict obstructive symptoms in women, but only smoking also predicts subsequent experience of poor health. Int J Med Sci. 2006;4:7–12.PubMedPubMedCentralGoogle Scholar
  71. 71.
    Kanervist M, Vasankari T, Laitinen T, Heliovaara M, Jpusilathi P, Saarelainen S. Low socioeconomic status is associated with chronic obstructive airway disease. Respir Med. 2011;105:1140–6.CrossRefGoogle Scholar
  72. 72.
    Bousquet J, Dahl R, Khaltaev N. Global Alliance against chronic respiratory disease. Allergy. 2007;62:216–23.CrossRefPubMedGoogle Scholar
  73. 73.
    Roberts MH, Borrego ME, Kharat AA, Marshik PL, Mapel DW. Economic evaluations of fluticasone-propionate/salmeterol combination therapy for chronic obstructive pulmonary disease: a review of published studies. Expert Rev Pharmacoecon Outcomes Res. 2016;16(2):167–92.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2018

Authors and Affiliations

  1. 1.National Centre for Respiratory Pharmacoeconomics and PharmacoepidemiologyCESFARVeronaItaly
  2. 2.Mondo Medico, Multidisciplinary and Rehabilitation Outpatient ClinicNovaraItaly

Personalised recommendations