INT J TUBERC LUNG DIS 18(6):737–743 Q 2014 The Union http://dx.doi.org/10.5588/ijtld.13.0634
Health care use and economic burden of patients with diagnosed chronic obstructive pulmonary disease in Korea C. Kim,* K. H. Yoo,† C. K. Rhee,‡ H. K. Yoon,§ Y. S. Kim,¶ S. W. Lee,# Y-M. Oh,# S-D. Lee,# J. H. Lee,** K-J. Kim,†† J-H. Kim,‡‡ Y. B. Park* *Department of Pulmonary and Critical Care Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, †Department of Internal Medicine, Konkuk University School of Medicine, Konkuk, ‡ Department of Internal Medicine, Seoul St Mary’s Hospital, Catholic University of Korea, Seoul, §Department of Internal Medicine, Yeouido St Mary’s Hospital, Catholic University of Korea, Seoul, ¶Department of Internal Medicine, Yonsei University College of Medicine, Seoul, #Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, **Department of Internal Medicine, School of Medicine, Ewha Womans University, Seoul, ††Department of Clinical Research Support, National Strategic Coordinating Center for Clinical Research, Seoul, ‡‡Department of Nursing, College of Medicine, Chosun University, Gwangju, Korea, Republic of Korea SUMMARY BACKGROUND:
The prevalence and economic burden of chronic obstructive pulmonary disease (COPD) are increasing worldwide. However, little information is available concerning COPD-associated health care use and costs in Korea. O B J E C T I V E : To analyse 1) health care use, medical costs and medication use in 2009, and 2) changes in costs and medication use over 5 years (2006–2010). D E S I G N : Using the database of the Korean Health Insurance Review and Assessment Service, COPD patients were identified by searching on both ICD-10 codes and COPD medication. R E S U LT S : A total of 192 496 COPD patients were identified in 2009. Total medical costs per person were
US$2803 6 3865; the average annual number of days of out-patient care and days of hospitalisation were respectively 40 6 36 and 11 6 33. Methylxanthine and systemic beta-agonists were the most frequently used drugs. However, the number of prescriptions for long-acting muscarinic antagonist increased rapidly. The total cost of COPD-related medications increased by 33.1% over 5 years. C O N C L U S I O N : The present study provides new insight into health care use and the economic burden of COPD in Korea. Changing patterns of COPD-related medication use could help inform COPD management policies. K E Y W O R D S : pulmonary disease; chronic obstructive; health care use; health care costs; drug prescriptions
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) is characterised by airflow obstruction with an FEV1/FVC (forced expiratory volume in 1 second/forced vital capacity) ratio of ,70% that is not fully reversible. With its increasing prevalence, COPD is predicted to be the fourth most frequent cause of death worldwide by 2030.1 A recent population-based epidemiological survey using data from the fourth Korean National Health and Nutritional Examination Survey (KNHANES IV) revealed that COPD prevalence in Korea was 13.4% among subjects aged 740 years, and that most patients were undiagnosed or under-treated.2
There are no precise estimates of COPD-related mortality in Korea; however, according to data from the Korean Statistical Information Service, chronic lower respiratory diseases were ranked as the seventh leading cause of death in 2010. Given the increasing prevalence of the disease and the potential for severe disability, COPD represents a substantial socio-economic burden. Data from the United States and Europe highlight the enormous burden of COPD in these countries; however, data from other countries are rare.3 There is also little information on COPD-related health care use in Korea.4 The analysis of health care use and costs in COPD patients is important for the development of health care plans for the proper management of COPD.
YBP and JHK contributed equally to this work.
Correspondence to: Yong Bum Park, Departments of Pulmonary and Critical Care Medicine, Hallym University Kangdong Sacred Heart Hospital, 445, Gil-dong, Gangdong-gu, Seoul 134-701, Korea. Tel: (þ82) 2 2225 2754. Fax: (þ82) 2 478 6925. e-mail: [email protected] Jinhee Kim, Department of Nursing, College of Medicine, Chosun University, 309 Pilmun-daero, Dong-gu, Gwangju 501759, Korea. Tel: (þ82) þ82-2-230-6329, Fax. þ82-62-232-9213. e-mail: [email protected] Article submitted 29 August 2013. Final version accepted 11 February 2014.
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Korea’s universal health insurance system is managed and supervised by the government. Nearly the entire Korean population is registered with the mandatory Korean National Health Insurance (KNHI). The Korean Health Insurance Review and Assessment Service (KHIRA) database has detailed information about diagnosis, health care use and medication, and is thus a reliable source for nationwide epidemiological evaluations.5 The purpose of the present study was to analyse health care use and the economic burden of COPD patients in Korea using the KHIRA database.
STUDY POPULATION AND METHODS Data sources We used the KHIRA 2009 database to define clinical characteristics and use of medical resources among COPD patients. Data from 2006 to 2010 were also used to analyse trends in health care use and medical costs. In 2008, the total number of beneficiaries of the compulsory national health insurance scheme was 50 001 027; medical aid was provided through a social welfare fund for 3.7% (n ¼ 1 841 339) of the population who were unable to pay the insurance premium.6 Almost all hospitals, clinics, public health centres and pharmacies are registered with the KNHI. The medical facility first files a claim with the KNHA, after which KHIRA assesses the claim based on diagnostic codes and medical records. Patient selection As pulmonary function test results were not available, an operational definition was used for extracting data on COPD patients from the KHIRA database. We searched for subjects with a principal or secondary diagnosis of COPD based on International Classification of Diseases-Tenth Revision (ICD-10) codes and medications prescribed. COPD patients were defined as subjects who met all of the following criteria: 1) age .40 years; 2) ICD-10 codes for COPD or emphysema (J42.x–J44.x, with the exception of J430); 3) use of more than one of the following COPD drugs at least twice per year: long-acting muscarinic antagonists (LAMAs), long-acting beta-2 agonists (LABAs), inhaled corticosteroids (ICS), ICSþLABA, short-acting muscarinic antagonist (SAMAs), shortacting beta-2 agonist (SABAs) or methylxanthine. Patients receiving more than one reimbursement per year due to cancer (C00.x–C97.x), renal failure (N17.x-N19.x) and/or cerebrovascular disease (I60.x–I69.x) were excluded from the study, as the enormous expenses reimbursed for the treatment of these diseases were difficult to distinguish from COPD-related medical costs. Outcomes The health care use and medical costs of patients
identified as having COPD were analysed over 1 year (2009). Analysis was confined to COPD-related use and cost. Health care use and costs not considered as COPD-related were excluded from the analysis, including for COPD patients. Only COPD-related medications (LAMA, LABA, ICS, ICSþLABA, SAMA, SABA, SAMAþSABA, systemic corticosteroids, systemic beta-agonists and methylxanthine) were included in the analysis. For outpatient care, only visits where the patient was given a primary or secondary diagnosis of COPD (J42.x– J44.x, except J430) and was prescribed COPDrelated medications were included in the analysis. For in-patient care, only admissions where the patient received a primary or secondary diagnosis of COPD (J42.x–J44.x, but not J430), a COPDrelated disease (pneumonia [J12.x-J17.x], pulmonary thromboembolism [I26, I26.0 and I26.9], dyspnoea [R06.0] or acute respiratory distress syndrome [J80]), or was prescribed COPD medications, were included in the study. Days of health care use were recorded separately for out- and in-patient care. Days of out-patient care use were included only for patients who had used outpatient services, while days of in-patient care use were included only for patients who had used in-patient care, including the emergency department (ED) and the intensive care unit. The total number of days of health care use was included for all patients who had used out- or in-patient services. All costs are presented in US dollars (1 USD ¼ 1152 Korean won, as of 20 July 2012). Baseline characteristics, health care use, medical costs and COPD drug use in 2009 were compared between patients using primary and secondary medical facilities and those who had used tertiary medical facilities. In Korea, primary and secondary medical facilities frequently act as primary care centres, and tertiary medical facilities as referral hospitals. Statistical analysis All statistical analyses were performed using SAS version 9.2 (Statistical Analysis Software Institute, Cary, NC, USA). The assumption of the normal distribution of data was tested using the Shapiro-Wilk statistic. Data are expressed as mean 6 standard deviation (SD). Ethics statement Approval for the present study (PIRB11-022) was obtained from the National Evidence-Based Healthcare Collaborating Agency (NECA) ethics committee. The requirement for informed consent from study participants was waived by the ethics review board.
Economic burden of COPD in Korea
RESULTS Baseline characteristics Of 192 496 COPD patients identified in 2009, the mean age was 69.3 6 10.3 years; 63.1% were male. Of the 192 496 COPD patients, 185 393 used primary and secondary medical facilities, while 134 722 used tertiary facilities. More than a third of the COPD patients (35.2%) had been hospitalised and 19.9% had a history of ED treatment. The proportion of patients who were hospitalised or had undergone ED treatment was higher among patients using tertiary facilities. Pulmonary function testing was far less frequently performed among patients attending primary and secondary facilities than in those attending tertiary facilities (11.1% vs. 40.6%). COPD patients attending tertiary facilities also had a higher rate of comorbidities such as ischaemic and congestive heart disease (Table 1). Health care use and medical costs Health care use and medical costs among COPD
patients in 2009 are shown in Table 2. Total medical costs per person were US$2802. The cost of out- and in-patient care per person was higher in patients attending tertiary medical facilities, and the proportion of in-patient cost was greater for those attending tertiary facilities than in those attending primary and secondary facilities (55.9% vs 29.1%). The average number of days of out-patient care was greater in patients attending primary and secondary facilities, while the average number days of inpatient care use was greater in those attending tertiary facilities. COPD-related medication use and costs Drugs prescribed for COPD and related costs in 2009 are shown in Table 3. In patients attending tertiary facilities, methylxanthine, ICSþLABA and LAMA were the most commonly prescribed COPD drugs. However, methylxanthine, systemic corticosteroids and systemic beta-agonists were more frequently used by patients attending primary and secondary facili-
Table 1 Baseline characteristics of subjects with chronic obstructive pulmonary disease by type of medical facility, Korea, 2009* Primary and secondary care facilities n (%)
Tertiary care facilities n (%)
Total n (%)
Total
185 393 (100)
134 722 (100)
192 496 (100)
Sex Male Female
115 911 (62.5) 69 482 (37.5)
90 155 (66.9) 44 567 (33.1)
121 410 (63.1) 71 086 (36.9)
Age, years Mean 6 SD 40–49 50–59 60–69 70–79 780
69.37 6 8 657 22 888 53 657 71 696 28 495
10.28 (4.7) (12.3) (28.9) (38.7) (15.4)
69.37 6 10.1 5 725 (4.2) 16 822 (12.5) 39 636 (29.4) 52 501 (39.0) 20 038 (14.9)
69.3 6 10.32 9 144 (4.8) 24 160 (12.6) 55 887 (29.0) 73 841 (38.4) 29 464 (15.3)
Insurance type Health insurance Medical aid
154 204 (83.2) 31 189 (16.8)
112 098 (83.2) 22 624 (16.8)
159 430 (82.8) 33 066 (17.2)
Hospitalisation Never Ever
157 250 (84.8) 28 143 (15.2)
85 022 (63.1) 49 700 (36.9)
124 793 (64.8) 67 703 (35.2)
ED visit Mean 6 SD Never Ever
0.04 6 0.27 180 454 (97.3) 4 939 (2.7)
0.40 6 0.87 99 927 (74.2) 34 795 (25.8)
0.31 6 0.81 154 281 (80.1) 38 215 (19.9)
Pulmonary function test Never Ever
164 733 (88.9) 20 660 (11.1)
80 017 (59.4) 54 705 (40.6)
121 630 (63.2) 70 866 (36.8)
Comorbidity Hypertension Ischaemic heart disease Congestive heart failure Metabolic syndrome Diabetes mellitus Osteoporosis Arthritis Depressive disorder Pneumothorax Anaemia
66 15 9 19 34 24 34 10
128 635 215 356 399 994 216 741 550 5 663
(35.7) (8.4) (5.0) (10.4) (18.6) (13.5) (18.5) (5.8) (0.3) (3.1)
* The two groups are not mutually exclusive. SD ¼ standard deviation; ED ¼ emergency department.
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49 23 9 19 24 10 7 7 1 3
018 245 740 604 353 772 500 608 938 926
(36.4) (17.3) (7.2) (14.6) (18.1) (8.0) (5.6) (5.6) (1.4) (2.9)
97 35 17 36 48 33 39 17 2 9
672 021 572 736 189 323 908 313 207 249
(50.7) (18.2) (9.1) (19.1) (25.0) (17.3) (20.7) (9.0) (1.1) (4.8)
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Table 2
Health care use and medical costs of COPD patients by type of medical facility in 2009* Primary and secondary care facilities (n ¼ 185 393) mean 6 SD
Tertiary care facilities (n ¼ 134 722) mean 6 SD
Total (n ¼ 192 496) mean 6 SD
Medical cost,† USD Out-patient care In-patient care Total cost
872.4 6 1104.66 357.65 6 1589.19 1230.05 6 1960.61
1020.58 6 1075.39 1291.57 6 3546.78 2312.15 6 3780.45
1554.41 6 1396.9 1248.24 6 3505.66 2802.65 6 3864.6
Days used† Out-patient care Days hospitalised Total days used
33.79 6 35.11 5.26 6 26.57 39.05 6 43.5
10.65 6 12.41 8.02 6 22.22 18.67 6 26.47
40.00 6 36.16 10.68 6 33.28 50.68 6 48.58
* The two groups are not mutually exclusive. † Costs or days used per person.
ties. The frequency of prescriptions for LAMA and ICSþLABA was very low in primary and secondary facilities compared to tertiary facilities. The total cost of COPD-related medications was higher in patients attending tertiary facilities than in those attending primary and secondary facilities ($30 796 462 vs. $11 956 206). Despite the frequent prescriptions of methylxanthine, systemic beta-agonists and systemic corticosteroids, the majority (approximately 71%) of the total medication costs were for ICSþLABA and LAMA. The cost of ICSþLABA and LAMA accounted for over 59% of total medication costs in patients attending primary and secondary facilities, despite the lower rates of prescription. Changes in medical costs over 5 years The number of COPD patients increased from 174 879 in 2006 to 193 985 in 2008, showing a 10.9% (n ¼ 19 106) increase over 3 years. From 2008, the number of COPD patients showed little change until 2010. However, total medical costs per COPD patient, including the costs of in- and out-patient care, increased gradually over the period by 25.3% ($585) (Figure 1). Table 3
Changes in COPD medication use and related costs over 5 years Changes in the pattern of drug prescriptions for COPD from 2006 to 2010 are shown in Figure 2. Methylxanthine and systemic beta-agonists were most frequently used over the 5 years; however, although overall prescription rates decreased gradually, the frequency of LAMA and ICSþLABA prescriptions increased rapidly over the period, with the rate of LAMA prescriptions increasing more than two-fold in 2010 compared to 2006. The total cost of COPD-related medication increased by 33.1% ($11 303 973) over 5 years. Despite the large number of methylxanthine, systemic betaagonist and systemic corticosteroid prescriptions, the cost of these drugs accounted for a relatively small proportion of total medication costs in 2010. The cost of ICSþLABA and LAMA comprised 48.9% of total medication costs in 2006, but rose to 73.6% of the total in 2010. The rate of increase in medication costs was highest for LAMAs, for which the cost more than doubled from 2006 to 2010 along with the rate of prescriptions; this accounted for the greatest proportion (36.9%) of total medication costs in 2010 (Figure 3).
COPD-related medication use and its cost during 2009* Primary and secondary care facilities (n ¼ 185 393)
ICS ICSþLABA LAMA LABA Systemic corticosteroid SAMA SABA SAMAþSABA Systemic beta-agonist Methylxanthine Total
Tertiary care facilities (n ¼ 134 722)
n (%)
Cost (US$)
n (%)
Cost (US$)
14 121 (7.62) 25 311 (13.65) 15 024 (8.10) 36 (0.02) 83 844 (45.23 11 876 (6.41) 37 371 (20.16) 2 145 (1.16) 80 381 (43.36) 112 072 (60.45)
308 781.58 4 128 150.26 3 020 803.59 1 745.32 296 566.65 207 499.96 551 828.20 131 711.77 1 315 101.60 1 994 017.11 11 956 206.03
13 572 (10.07) 45 345 (33.65) 44 088 (32.71) 122 (0.09) 33 290 (24.70 24 472 (18.16) 37 930 (28.14) 3 305 (2.45) 38 082 (28.26) 75 781 (56.23)
680 747.77 11 640 427.78 11 451 041.92 10 999.79 243 213.61 612 202.93 602 613.54 129 115.62 1 749 162.90 3 676 936.46 30 796 462.32
Total (n ¼ 192 496) n (%)
Cost (US$)
25 980 (13.50) 63 636 (33.06) 15 54 872 (28.51) 14 152 (0.08) 101 750 (52.86) 33 871 (17.60) 64 717 (33.62) 1 5 091 (2.64) 105 865 (55.00) 3 157 519 (81.83) 5 42
989 768 471 12 539 819 154 260 064 670 752
529.35 578.04 845.51 745.11 780.25 702.89 441.74 827.39 264.51 953.57 668.35
* The two groups are not mutually exclusive. COPD ¼ chronic obstructive pulmonary disease; ICS ¼ inhaled corticosteroid; LABA ¼ long-acting beta-2 agonist; LAMA ¼ long-acting muscarinic antagonist; SAMA ¼ short-acting muscarinic antagonist; SABA ¼ short-acting beta-2 agonist.
Economic burden of COPD in Korea
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Figure 1 Changes in total medical costs and in out- and in-patient care costs per COPD patient over 5 years. COPD ¼ chronic obstructive pulmonary disease.
DISCUSSION The present study was designed to examine health care use and the economic burden of COPD patients in Korea based on KNHI data. According to Statistics Korea, the population aged .40 years was 22 638 731 in 2009. Based on the COPD prevalence in KNHANES IV, it may therefore be estimated that the total number of COPD patients in 2009 was 3 033 560. Of these, only a small portion of patients (6.3%) actually used medical facilities, indicating that early diagnosis of COPD was not common. Early diagnosis of COPD is important, as the disease is known to be irreversible in its later stages.7 However, signs or symptoms are usually absent or ignored in most
patients with mild to moderate COPD. COPD is often at an advanced stage at the time of diagnosis, thus limiting the benefits that could potentially be obtained from early intervention with measures such as smoking cessation and increased exercise.8 A significant proportion of failures in early detection of COPD occurs in primary and secondary facilities. As seen in the present study, the lower rates of pulmonary function testing in these facilities inevitably leads to underdiagnosis. This also suggests that a large number of primary care physicians are still not aware of the disease. In the present study, the proportion of COPD patients with a history of hospitalisation or ED visits was greater in tertiary than primary and secondary
Figure 2 Changes in the pattern of COPD-related drug prescriptions over 5 years. ICS ¼ inhaled corticosteroid; LAMA ¼ long-acting muscarinic antagonist; LABA ¼ long-acting beta-2 agonist; SAMA ¼ short-acting muscarinic antagonist; SABA ¼ short-acting beta-2 agonist; OCS ¼ oral corticosteroid; COPD ¼ chronic obstructive pulmonary disease.
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Figure 3 Changes in the cost of each COPD-related drug over 5 years. ICS ¼ inhaled corticosteroid; LAMA ¼ long-acting muscarinic antagonist; LABA ¼ long-acting beta-2 agonist; SAMA ¼ short-acting muscarinic antagonist; SABA ¼ short-acting beta-2 agonist; OCS ¼ oral corticosteroid; COPD ¼ chronic obstructive pulmonary disease.
facilities. The cost of in-patient care per person was higher in COPD patients attending tertiary facilities, as was the average number of days of hospitalisation. It is well known that COPD exacerbation and COPD severity are major causes of hospitalisation.9,10 Our findings therefore suggest that patients attending tertiary facilities were more likely to have advanced disease and/or frequent exacerbations. However, the mean number of out-patient visits and total number of days of health care use per person were higher in those attending primary and secondary facilities. In general, frequent visits may be associated with advanced disease and poor disease control. This discrepancy is probably due to differences in physicians’ behaviour. Primary care physicians in Korea tend to schedule follow-up visits earlier, while physicians in tertiary referral centres do so at at least 3-monthly intervals. COPD is associated with systemic manifestations and comorbid conditions that affect health outcomes, increase the risk of hospitalisation and death, and account for more than 50% of health care resources used for COPD.11 Cardiovascular disease is a major comorbidity and probably the most frequent and most significant.12,13 A previous report demonstrated that the prevalence of cardiovascular disease was one of the major determinants of the overall cost of COPD.14 In the present study, ischaemic heart disease and congestive heart failure, which may directly affect mortality, were more commonly observed among COPD patients attending tertiary facilities. The reason for the greater cost of out- and in-patient
care in patients attending tertiary facilities can be partly explained by the higher rates of cardiovascular comorbidities. The number of COPD patients increased by 10.9% from 2006 to 2008, and has shown little change since then. This increase was partly attributable to a natural increase in the aging population and continued exposure to risk factors. Improved physician understanding of COPD may have contributed to the increase in the number of COPD patients until 2008, but was probably not sufficient to reach a meaningful increase in the COPD population since 2009. However, total medical costs gradually increased over the study period, mainly due to a steady increase in prescription rates for LAMA and ICSþLABA, which are more expensive than other COPD drugs. In the present study, total average direct health care costs per COPD patient were US$2800 in Korea in 2009, which are slightly higher than in Canada and the United States,15 and represent a considerable economic and social burden. The reason for the relatively high costs was not fully understood, but they are partly attributable to easy access to health care and hospitalisation. To our knowledge, this is the first study to perform a nationwide analysis of the pattern of COPD-related drug prescriptions and changes over time using a national health insurance database. The number of LAMA and ICSþLABA prescriptions was very low in primary and secondary facilities compared to tertiary facilities. However, the overall frequency of LAMA and ICSþLABA prescriptions increased steeply; in
Economic burden of COPD in Korea
particular, the use of LAMA more than doubled during the 5 years of the study. This may have been partly due to increased awareness about COPD among physicians, but was mainly due to the launch of tiotropium bromide in Korea in February 2005. Despite the increase in the number of prescriptions for LAMA, annual rates of hospitalisation and ED visits and mean days of hospitalisation per patient did not change significantly over the 5 years (data not shown). It is well known that the use of LAMA is more likely to reduce the number of exacerbations and COPD-related hospitalisations.16,17 However, in our data, the mean number of actual LAMA prescriptions per patient was only 2.03 in 2009. This might be due to a high proportion of mild COPD and undertreatment. The high cost of inhalers may have led to non-adherence in some patients.18 Another interesting finding was the popular use of methylxanthine and systemic beta-agonists throughout the study period. This reflects the underutilisation of inhaled medications in primary care and inadequate adherence to current treatment guidelines for COPD in real practice. Although the cost of inhaled medications is high, guideline-based prescription and treatment should be recommended to reduce exacerbation and improve health-related quality of life in COPD patients. The present study had several limitations. First, as the pulmonary function testing results were not available, patients enrolled in the study did not have a proven diagnosis of COPD (FEV1/FVC ratio). Second, data on smoking history and occupational or environmental exposure were not available. However, the definition of COPD was largely based on ICD-10 codes for COPD or emphysema, and it is probable that physicians attributed ICD-10 codes on the understanding that cigarette smoking is the most common risk factor for COPD. Third, although indirect cost estimations are useful in assessing the true economic and social burden of a disease, we could not estimate indirect costs such as those due to lost work and productivity. It should be noted in this regard that more than half of the total annual costs of COPD in the United States were indirect.19
CONCLUSIONS The present study provides new insight into health care use and medical costs for COPD in Korea. Changing patterns in COPD-related medication use are a useful indicator of COPD management in real practice. Our findings provide fundamental data necessary to inform COPD management policies. Training programmes for primary care physicians on early diagnosis and intervention and a state-of-the-art review of COPD management would be useful.
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Acknowledgements This study was supported by a grant from the Korea Healthcare Technology R&D Project (A102065). Conflicts of interest: none declared.
References 1 Mathers C D, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLOS MED 2006; 3: e442. 2 Yoo K H, Kim Y S, Sheen S S, et al. Prevalence of chronic obstructive pulmonary disease in Korea: the fourth Korean National Health and Nutrition Examination Survey, 2008. Respirology 2011; 16: 659–665. 3 Pauwels R A, Rabe K F. Burden and clinical features of chronic obstructive pulmonary disease (COPD). Lancet 2004; 364: 613–620. 4 Jung J Y, Kang Y A, Park M S, et al. Chronic obstructive lung disease-related health care utilisation in Korean adults with obstructive lung disease. Int J Tuberc Lung Dis 2011; 15: 824– 829. 5 Lee Y H, Yoon S J, Kim E J, Kim Y A, Seo H Y, Oh I H. Economic burden of asthma in Korea. Allergy Asthma Proc 2011; 32: 35–40. 6 Korean National Health Insurance Cooperation. Annual report of national health insurance statistics, 2008. Seoul, Korea: Division of Statistical Analysis, Korean National Health Insurance Cooperation, 2008. 7 Stockley R A. Progression of chronic obstructive pulmonary disease: impact of inflammation, comorbidities and therapeutic intervention. Curr Med Res Opin 2009; 25: 1235–1245. 8 Bunker J M, Reddel H K, Dennis S M, et al. A pragmatic cluster randomized controlled trial of early intervention for chronic obstructive pulmonary disease by practice nurse-general practitioner teams: Study Protocol. Implement Sci 2012; 7: 83. 9 Hoogendoorn M, Feenstra T L, Hoogenveen R T, Al M, Molken M R. Association between lung function and exacer¨ bation frequency in patients with COPD. Int J Chron Obstruct Pulmon Dis 2010; 5: 435–444. 10 Hurst J R, Vestbo J, Anzueto A, et al. Susceptibility to exacerbation in chronic obstructive pulmonary disease. N Engl J Med 2010; 363: 1128–1138. 11 Decramer M, Janssens W, Miravitlles M. Chronic obstructive pulmonary disease. Lancet 2012; 379: 1341–1351. 12 Barnes P J, Celli B R. Systemic manifestations and comorbidities of COPD. Eur Respir J 2009; 33: 1165–1185. 13 Fabbri L M, Luppi F, Begh´e B, Rabe K F. Complex chronic comorbidities of COPD. Eur Respir J 2008; 31: 204–212. 14 de Miguel Diez J, Carrasco Garrido P, Garc´ıa Carballo M, et al. Determinants and predictors of the cost of COPD in primary care: a Spanish perspective. Int J Chron Obstruct Pulmon Dis 2008; 3: 701–712. 15 Donner C F, Virchow J C, Lusuardi M. Pharmacoeconomics in COPD and inappropriateness of diagnostics, management and treatment. Respir Med 2011; 105: 828–837. 16 Van den Bruel A, Gailly J, Neyt M. Does tiotropium lower exacerbation and hospitalization frequency in COPD patients: results of a meta-analysis. BMC Pulm Med 2010; 10: 50. 17 Tashkin D P, Celli B, Senn S, et al. A 4-year trial of tiotropium in chronic obstructive pulmonary disease. N Engl J Med 2008; 359: 1543–1554. 18 Castaldi P J, Rogers W H, Safran D G, Wilson IB. Inhaler costs and medication nonadherence among seniors with chronic pulmonary disease. Chest 2010; 138: 614–620. 19 Foster T S, Miller J D, Marton J P, Caloyeras J P, Russell M W, Menzin J. Assessment of the economic burden of COPD in the US: a review and synthesis of the literature. COPD 2006; 3: 211–218.
Economic burden of COPD in Korea
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RESUME
La pr´evalence et le fardeau e´ conomique des maladies pulmonaires chroniques obstructives (BPCO) augmentent dans le monde. Cependant, on dispose de peu d’information sur l’utilisation des soins de sant´e et les couts ˆ li´es aux BPCO en Cor´ee. O B J E C T I F : Analyser l’utilisation des soins de sant´e, les couts ˆ m´edicaux et l’utilisation des m´edicaments en 2009 ainsi que les modifications des couts ˆ et du choix des m´edicaments sur 5 ans (de 2006 a` 2010). S C H E´ M A : Grace ˆ a` la base de donn´ees des services d’´evaluation de la s´ecurit´e sociale cor´eenne, les patients atteints de BPCO ont e´ t´e identifi´es en recherchant a` la fois le code ICD-10 et les m´edicaments des BPCO. R E´ S U LT A T S : Un total de 192 496 patients avec BPCO a e´ t´e identifi´e en 2009. Le cout ˆ m´edical total par patient e´ tait de 2803 6 3865 US$ et le nombre moyen de jours de CONTEXTE :
consultation et d’hospitalisation par an e´ tait respectivement de 40 6 36 et de 11 6 33 jours. La methylxanthine et les beta-agonistes syst´emiques e´ taient les m´edicaments les plus utilis´es. Cependant, la fr´equence de prescription des antagonistes muscariniques a` lib´eration prolong´ee a augment´e rapidement. Le cout ˆ total des m´edicaments li´es aux BPCO a augment´e de 33,1% en 5 ans. C O N C L U S I O N : Cette e´ tude fournit une nouvelle vision de l’utilisation des soins de sante´ et du fardeau e´ conomique des BPCO en Cor´ee. Les modifications du profil d’utilisation des m´edicaments li´es aux BPCO sont e´ galement une information importante. Elles peuvent eˆ tre une donn´ee fondamentale dans l’´elaboration d’une politique de gestion des BPCO.
RESUMEN D E R E F E R E N C I A: La prevalencia de la enfermedad pulmonar obstructiva cronica ´ (EPOC) con la carga economica ´ que impone esta´n en aumento en todo el mundo. Sin embargo, se cuenta con poca informacion ´ sobre la utilizacion ´ de los sistemas de salud en relacion ´ con la EPOC y los costos que acarrea en Corea. O B J E T I V O: Analizar la utilizacion ´ de los servicios de salud, los costos de atencion ´ m´edica y el uso de medicamentos en el ano ´ ˜ 2009 y evaluar la evolucion de los costos y el uso de medicamentos durante un per´ıodo de 5 anos ˜ (de 2006 a 2010). M E´ T O D O: Se incluyeron los pacientes con EPOC de la base de datos del Servicio Coreano de Evaluacion ´ y Revision ´ del Seguro M´edico tras una busqueda ´ por el codigo ´ del CIE-10 y por medicamentos para EPOC. R E S U LT A D O S: Se detectaron 192 496 pacientes con EPOC en el 2009. El costo m´edico total por persona fue MARCO
US$ 2803 6 3865; el promedio anual de d´ıas de consulta externa por paciente fue 40 6 36 y el de los d´ıas de hospitalizacion ´ fue 11 6 33. Los medicamentos ma´s utilizados fueron las metilxantinas y los agonistas beta sist´emicos. Sin embargo, la frecuencia de recetas de antagonistas muscar´ınicos de acci on ´ prolongada aument o´ ra´ pidamente. El costo total de los medicamentos relacionados con la EPOC revelo´ un aumento del 33,1% durante los 5 anos. ˜ ´ N: El presente estudio aporta una nueva CONCLUSIO perspectiva sobre la utilizacion ´ de la atencion ´ de salud y la carga economica ´ en relacion ´ con la EPOC en Corea. La modificacion ´ en el tipo de utilizacion ´ de los medicamentos para el EPOC es tambi´en una informaci on ´ valiosa. Estos resultados pueden fundamentar el establecimiento de las directrices del tratamiento de la EPOC.
Health care use and economic burden of patients with diagnosed chronic obstructive pulmonary disease in Korea C. Kim,* K. H. Yoo,† C. K. Rhee,‡ H. K. Yoon,§ Y. S. Kim,¶ S. W. Lee,# Y-M. Oh,# S-D. Lee,# J. H. Lee,** K-J. Kim,†† J-H. Kim,‡‡ Y. B. Park* *Department of Pulmonary and Critical Care Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, †Department of Internal Medicine, Konkuk University School of Medicine, Konkuk, ‡ Department of Internal Medicine, Seoul St Mary’s Hospital, Catholic University of Korea, Seoul, §Department of Internal Medicine, Yeouido St Mary’s Hospital, Catholic University of Korea, Seoul, ¶Department of Internal Medicine, Yonsei University College of Medicine, Seoul, #Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, **Department of Internal Medicine, School of Medicine, Ewha Womans University, Seoul, ††Department of Clinical Research Support, National Strategic Coordinating Center for Clinical Research, Seoul, ‡‡Department of Nursing, College of Medicine, Chosun University, Gwangju, Korea, Republic of Korea SUMMARY BACKGROUND:
The prevalence and economic burden of chronic obstructive pulmonary disease (COPD) are increasing worldwide. However, little information is available concerning COPD-associated health care use and costs in Korea. O B J E C T I V E : To analyse 1) health care use, medical costs and medication use in 2009, and 2) changes in costs and medication use over 5 years (2006–2010). D E S I G N : Using the database of the Korean Health Insurance Review and Assessment Service, COPD patients were identified by searching on both ICD-10 codes and COPD medication. R E S U LT S : A total of 192 496 COPD patients were identified in 2009. Total medical costs per person were
US$2803 6 3865; the average annual number of days of out-patient care and days of hospitalisation were respectively 40 6 36 and 11 6 33. Methylxanthine and systemic beta-agonists were the most frequently used drugs. However, the number of prescriptions for long-acting muscarinic antagonist increased rapidly. The total cost of COPD-related medications increased by 33.1% over 5 years. C O N C L U S I O N : The present study provides new insight into health care use and the economic burden of COPD in Korea. Changing patterns of COPD-related medication use could help inform COPD management policies. K E Y W O R D S : pulmonary disease; chronic obstructive; health care use; health care costs; drug prescriptions
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) is characterised by airflow obstruction with an FEV1/FVC (forced expiratory volume in 1 second/forced vital capacity) ratio of ,70% that is not fully reversible. With its increasing prevalence, COPD is predicted to be the fourth most frequent cause of death worldwide by 2030.1 A recent population-based epidemiological survey using data from the fourth Korean National Health and Nutritional Examination Survey (KNHANES IV) revealed that COPD prevalence in Korea was 13.4% among subjects aged 740 years, and that most patients were undiagnosed or under-treated.2
There are no precise estimates of COPD-related mortality in Korea; however, according to data from the Korean Statistical Information Service, chronic lower respiratory diseases were ranked as the seventh leading cause of death in 2010. Given the increasing prevalence of the disease and the potential for severe disability, COPD represents a substantial socio-economic burden. Data from the United States and Europe highlight the enormous burden of COPD in these countries; however, data from other countries are rare.3 There is also little information on COPD-related health care use in Korea.4 The analysis of health care use and costs in COPD patients is important for the development of health care plans for the proper management of COPD.
YBP and JHK contributed equally to this work.
Correspondence to: Yong Bum Park, Departments of Pulmonary and Critical Care Medicine, Hallym University Kangdong Sacred Heart Hospital, 445, Gil-dong, Gangdong-gu, Seoul 134-701, Korea. Tel: (þ82) 2 2225 2754. Fax: (þ82) 2 478 6925. e-mail: [email protected] Jinhee Kim, Department of Nursing, College of Medicine, Chosun University, 309 Pilmun-daero, Dong-gu, Gwangju 501759, Korea. Tel: (þ82) þ82-2-230-6329, Fax. þ82-62-232-9213. e-mail: [email protected] Article submitted 29 August 2013. Final version accepted 11 February 2014.
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Korea’s universal health insurance system is managed and supervised by the government. Nearly the entire Korean population is registered with the mandatory Korean National Health Insurance (KNHI). The Korean Health Insurance Review and Assessment Service (KHIRA) database has detailed information about diagnosis, health care use and medication, and is thus a reliable source for nationwide epidemiological evaluations.5 The purpose of the present study was to analyse health care use and the economic burden of COPD patients in Korea using the KHIRA database.
STUDY POPULATION AND METHODS Data sources We used the KHIRA 2009 database to define clinical characteristics and use of medical resources among COPD patients. Data from 2006 to 2010 were also used to analyse trends in health care use and medical costs. In 2008, the total number of beneficiaries of the compulsory national health insurance scheme was 50 001 027; medical aid was provided through a social welfare fund for 3.7% (n ¼ 1 841 339) of the population who were unable to pay the insurance premium.6 Almost all hospitals, clinics, public health centres and pharmacies are registered with the KNHI. The medical facility first files a claim with the KNHA, after which KHIRA assesses the claim based on diagnostic codes and medical records. Patient selection As pulmonary function test results were not available, an operational definition was used for extracting data on COPD patients from the KHIRA database. We searched for subjects with a principal or secondary diagnosis of COPD based on International Classification of Diseases-Tenth Revision (ICD-10) codes and medications prescribed. COPD patients were defined as subjects who met all of the following criteria: 1) age .40 years; 2) ICD-10 codes for COPD or emphysema (J42.x–J44.x, with the exception of J430); 3) use of more than one of the following COPD drugs at least twice per year: long-acting muscarinic antagonists (LAMAs), long-acting beta-2 agonists (LABAs), inhaled corticosteroids (ICS), ICSþLABA, short-acting muscarinic antagonist (SAMAs), shortacting beta-2 agonist (SABAs) or methylxanthine. Patients receiving more than one reimbursement per year due to cancer (C00.x–C97.x), renal failure (N17.x-N19.x) and/or cerebrovascular disease (I60.x–I69.x) were excluded from the study, as the enormous expenses reimbursed for the treatment of these diseases were difficult to distinguish from COPD-related medical costs. Outcomes The health care use and medical costs of patients
identified as having COPD were analysed over 1 year (2009). Analysis was confined to COPD-related use and cost. Health care use and costs not considered as COPD-related were excluded from the analysis, including for COPD patients. Only COPD-related medications (LAMA, LABA, ICS, ICSþLABA, SAMA, SABA, SAMAþSABA, systemic corticosteroids, systemic beta-agonists and methylxanthine) were included in the analysis. For outpatient care, only visits where the patient was given a primary or secondary diagnosis of COPD (J42.x– J44.x, except J430) and was prescribed COPDrelated medications were included in the analysis. For in-patient care, only admissions where the patient received a primary or secondary diagnosis of COPD (J42.x–J44.x, but not J430), a COPDrelated disease (pneumonia [J12.x-J17.x], pulmonary thromboembolism [I26, I26.0 and I26.9], dyspnoea [R06.0] or acute respiratory distress syndrome [J80]), or was prescribed COPD medications, were included in the study. Days of health care use were recorded separately for out- and in-patient care. Days of out-patient care use were included only for patients who had used outpatient services, while days of in-patient care use were included only for patients who had used in-patient care, including the emergency department (ED) and the intensive care unit. The total number of days of health care use was included for all patients who had used out- or in-patient services. All costs are presented in US dollars (1 USD ¼ 1152 Korean won, as of 20 July 2012). Baseline characteristics, health care use, medical costs and COPD drug use in 2009 were compared between patients using primary and secondary medical facilities and those who had used tertiary medical facilities. In Korea, primary and secondary medical facilities frequently act as primary care centres, and tertiary medical facilities as referral hospitals. Statistical analysis All statistical analyses were performed using SAS version 9.2 (Statistical Analysis Software Institute, Cary, NC, USA). The assumption of the normal distribution of data was tested using the Shapiro-Wilk statistic. Data are expressed as mean 6 standard deviation (SD). Ethics statement Approval for the present study (PIRB11-022) was obtained from the National Evidence-Based Healthcare Collaborating Agency (NECA) ethics committee. The requirement for informed consent from study participants was waived by the ethics review board.
Economic burden of COPD in Korea
RESULTS Baseline characteristics Of 192 496 COPD patients identified in 2009, the mean age was 69.3 6 10.3 years; 63.1% were male. Of the 192 496 COPD patients, 185 393 used primary and secondary medical facilities, while 134 722 used tertiary facilities. More than a third of the COPD patients (35.2%) had been hospitalised and 19.9% had a history of ED treatment. The proportion of patients who were hospitalised or had undergone ED treatment was higher among patients using tertiary facilities. Pulmonary function testing was far less frequently performed among patients attending primary and secondary facilities than in those attending tertiary facilities (11.1% vs. 40.6%). COPD patients attending tertiary facilities also had a higher rate of comorbidities such as ischaemic and congestive heart disease (Table 1). Health care use and medical costs Health care use and medical costs among COPD
patients in 2009 are shown in Table 2. Total medical costs per person were US$2802. The cost of out- and in-patient care per person was higher in patients attending tertiary medical facilities, and the proportion of in-patient cost was greater for those attending tertiary facilities than in those attending primary and secondary facilities (55.9% vs 29.1%). The average number of days of out-patient care was greater in patients attending primary and secondary facilities, while the average number days of inpatient care use was greater in those attending tertiary facilities. COPD-related medication use and costs Drugs prescribed for COPD and related costs in 2009 are shown in Table 3. In patients attending tertiary facilities, methylxanthine, ICSþLABA and LAMA were the most commonly prescribed COPD drugs. However, methylxanthine, systemic corticosteroids and systemic beta-agonists were more frequently used by patients attending primary and secondary facili-
Table 1 Baseline characteristics of subjects with chronic obstructive pulmonary disease by type of medical facility, Korea, 2009* Primary and secondary care facilities n (%)
Tertiary care facilities n (%)
Total n (%)
Total
185 393 (100)
134 722 (100)
192 496 (100)
Sex Male Female
115 911 (62.5) 69 482 (37.5)
90 155 (66.9) 44 567 (33.1)
121 410 (63.1) 71 086 (36.9)
Age, years Mean 6 SD 40–49 50–59 60–69 70–79 780
69.37 6 8 657 22 888 53 657 71 696 28 495
10.28 (4.7) (12.3) (28.9) (38.7) (15.4)
69.37 6 10.1 5 725 (4.2) 16 822 (12.5) 39 636 (29.4) 52 501 (39.0) 20 038 (14.9)
69.3 6 10.32 9 144 (4.8) 24 160 (12.6) 55 887 (29.0) 73 841 (38.4) 29 464 (15.3)
Insurance type Health insurance Medical aid
154 204 (83.2) 31 189 (16.8)
112 098 (83.2) 22 624 (16.8)
159 430 (82.8) 33 066 (17.2)
Hospitalisation Never Ever
157 250 (84.8) 28 143 (15.2)
85 022 (63.1) 49 700 (36.9)
124 793 (64.8) 67 703 (35.2)
ED visit Mean 6 SD Never Ever
0.04 6 0.27 180 454 (97.3) 4 939 (2.7)
0.40 6 0.87 99 927 (74.2) 34 795 (25.8)
0.31 6 0.81 154 281 (80.1) 38 215 (19.9)
Pulmonary function test Never Ever
164 733 (88.9) 20 660 (11.1)
80 017 (59.4) 54 705 (40.6)
121 630 (63.2) 70 866 (36.8)
Comorbidity Hypertension Ischaemic heart disease Congestive heart failure Metabolic syndrome Diabetes mellitus Osteoporosis Arthritis Depressive disorder Pneumothorax Anaemia
66 15 9 19 34 24 34 10
128 635 215 356 399 994 216 741 550 5 663
(35.7) (8.4) (5.0) (10.4) (18.6) (13.5) (18.5) (5.8) (0.3) (3.1)
* The two groups are not mutually exclusive. SD ¼ standard deviation; ED ¼ emergency department.
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49 23 9 19 24 10 7 7 1 3
018 245 740 604 353 772 500 608 938 926
(36.4) (17.3) (7.2) (14.6) (18.1) (8.0) (5.6) (5.6) (1.4) (2.9)
97 35 17 36 48 33 39 17 2 9
672 021 572 736 189 323 908 313 207 249
(50.7) (18.2) (9.1) (19.1) (25.0) (17.3) (20.7) (9.0) (1.1) (4.8)
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Table 2
Health care use and medical costs of COPD patients by type of medical facility in 2009* Primary and secondary care facilities (n ¼ 185 393) mean 6 SD
Tertiary care facilities (n ¼ 134 722) mean 6 SD
Total (n ¼ 192 496) mean 6 SD
Medical cost,† USD Out-patient care In-patient care Total cost
872.4 6 1104.66 357.65 6 1589.19 1230.05 6 1960.61
1020.58 6 1075.39 1291.57 6 3546.78 2312.15 6 3780.45
1554.41 6 1396.9 1248.24 6 3505.66 2802.65 6 3864.6
Days used† Out-patient care Days hospitalised Total days used
33.79 6 35.11 5.26 6 26.57 39.05 6 43.5
10.65 6 12.41 8.02 6 22.22 18.67 6 26.47
40.00 6 36.16 10.68 6 33.28 50.68 6 48.58
* The two groups are not mutually exclusive. † Costs or days used per person.
ties. The frequency of prescriptions for LAMA and ICSþLABA was very low in primary and secondary facilities compared to tertiary facilities. The total cost of COPD-related medications was higher in patients attending tertiary facilities than in those attending primary and secondary facilities ($30 796 462 vs. $11 956 206). Despite the frequent prescriptions of methylxanthine, systemic beta-agonists and systemic corticosteroids, the majority (approximately 71%) of the total medication costs were for ICSþLABA and LAMA. The cost of ICSþLABA and LAMA accounted for over 59% of total medication costs in patients attending primary and secondary facilities, despite the lower rates of prescription. Changes in medical costs over 5 years The number of COPD patients increased from 174 879 in 2006 to 193 985 in 2008, showing a 10.9% (n ¼ 19 106) increase over 3 years. From 2008, the number of COPD patients showed little change until 2010. However, total medical costs per COPD patient, including the costs of in- and out-patient care, increased gradually over the period by 25.3% ($585) (Figure 1). Table 3
Changes in COPD medication use and related costs over 5 years Changes in the pattern of drug prescriptions for COPD from 2006 to 2010 are shown in Figure 2. Methylxanthine and systemic beta-agonists were most frequently used over the 5 years; however, although overall prescription rates decreased gradually, the frequency of LAMA and ICSþLABA prescriptions increased rapidly over the period, with the rate of LAMA prescriptions increasing more than two-fold in 2010 compared to 2006. The total cost of COPD-related medication increased by 33.1% ($11 303 973) over 5 years. Despite the large number of methylxanthine, systemic betaagonist and systemic corticosteroid prescriptions, the cost of these drugs accounted for a relatively small proportion of total medication costs in 2010. The cost of ICSþLABA and LAMA comprised 48.9% of total medication costs in 2006, but rose to 73.6% of the total in 2010. The rate of increase in medication costs was highest for LAMAs, for which the cost more than doubled from 2006 to 2010 along with the rate of prescriptions; this accounted for the greatest proportion (36.9%) of total medication costs in 2010 (Figure 3).
COPD-related medication use and its cost during 2009* Primary and secondary care facilities (n ¼ 185 393)
ICS ICSþLABA LAMA LABA Systemic corticosteroid SAMA SABA SAMAþSABA Systemic beta-agonist Methylxanthine Total
Tertiary care facilities (n ¼ 134 722)
n (%)
Cost (US$)
n (%)
Cost (US$)
14 121 (7.62) 25 311 (13.65) 15 024 (8.10) 36 (0.02) 83 844 (45.23 11 876 (6.41) 37 371 (20.16) 2 145 (1.16) 80 381 (43.36) 112 072 (60.45)
308 781.58 4 128 150.26 3 020 803.59 1 745.32 296 566.65 207 499.96 551 828.20 131 711.77 1 315 101.60 1 994 017.11 11 956 206.03
13 572 (10.07) 45 345 (33.65) 44 088 (32.71) 122 (0.09) 33 290 (24.70 24 472 (18.16) 37 930 (28.14) 3 305 (2.45) 38 082 (28.26) 75 781 (56.23)
680 747.77 11 640 427.78 11 451 041.92 10 999.79 243 213.61 612 202.93 602 613.54 129 115.62 1 749 162.90 3 676 936.46 30 796 462.32
Total (n ¼ 192 496) n (%)
Cost (US$)
25 980 (13.50) 63 636 (33.06) 15 54 872 (28.51) 14 152 (0.08) 101 750 (52.86) 33 871 (17.60) 64 717 (33.62) 1 5 091 (2.64) 105 865 (55.00) 3 157 519 (81.83) 5 42
989 768 471 12 539 819 154 260 064 670 752
529.35 578.04 845.51 745.11 780.25 702.89 441.74 827.39 264.51 953.57 668.35
* The two groups are not mutually exclusive. COPD ¼ chronic obstructive pulmonary disease; ICS ¼ inhaled corticosteroid; LABA ¼ long-acting beta-2 agonist; LAMA ¼ long-acting muscarinic antagonist; SAMA ¼ short-acting muscarinic antagonist; SABA ¼ short-acting beta-2 agonist.
Economic burden of COPD in Korea
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Figure 1 Changes in total medical costs and in out- and in-patient care costs per COPD patient over 5 years. COPD ¼ chronic obstructive pulmonary disease.
DISCUSSION The present study was designed to examine health care use and the economic burden of COPD patients in Korea based on KNHI data. According to Statistics Korea, the population aged .40 years was 22 638 731 in 2009. Based on the COPD prevalence in KNHANES IV, it may therefore be estimated that the total number of COPD patients in 2009 was 3 033 560. Of these, only a small portion of patients (6.3%) actually used medical facilities, indicating that early diagnosis of COPD was not common. Early diagnosis of COPD is important, as the disease is known to be irreversible in its later stages.7 However, signs or symptoms are usually absent or ignored in most
patients with mild to moderate COPD. COPD is often at an advanced stage at the time of diagnosis, thus limiting the benefits that could potentially be obtained from early intervention with measures such as smoking cessation and increased exercise.8 A significant proportion of failures in early detection of COPD occurs in primary and secondary facilities. As seen in the present study, the lower rates of pulmonary function testing in these facilities inevitably leads to underdiagnosis. This also suggests that a large number of primary care physicians are still not aware of the disease. In the present study, the proportion of COPD patients with a history of hospitalisation or ED visits was greater in tertiary than primary and secondary
Figure 2 Changes in the pattern of COPD-related drug prescriptions over 5 years. ICS ¼ inhaled corticosteroid; LAMA ¼ long-acting muscarinic antagonist; LABA ¼ long-acting beta-2 agonist; SAMA ¼ short-acting muscarinic antagonist; SABA ¼ short-acting beta-2 agonist; OCS ¼ oral corticosteroid; COPD ¼ chronic obstructive pulmonary disease.
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Figure 3 Changes in the cost of each COPD-related drug over 5 years. ICS ¼ inhaled corticosteroid; LAMA ¼ long-acting muscarinic antagonist; LABA ¼ long-acting beta-2 agonist; SAMA ¼ short-acting muscarinic antagonist; SABA ¼ short-acting beta-2 agonist; OCS ¼ oral corticosteroid; COPD ¼ chronic obstructive pulmonary disease.
facilities. The cost of in-patient care per person was higher in COPD patients attending tertiary facilities, as was the average number of days of hospitalisation. It is well known that COPD exacerbation and COPD severity are major causes of hospitalisation.9,10 Our findings therefore suggest that patients attending tertiary facilities were more likely to have advanced disease and/or frequent exacerbations. However, the mean number of out-patient visits and total number of days of health care use per person were higher in those attending primary and secondary facilities. In general, frequent visits may be associated with advanced disease and poor disease control. This discrepancy is probably due to differences in physicians’ behaviour. Primary care physicians in Korea tend to schedule follow-up visits earlier, while physicians in tertiary referral centres do so at at least 3-monthly intervals. COPD is associated with systemic manifestations and comorbid conditions that affect health outcomes, increase the risk of hospitalisation and death, and account for more than 50% of health care resources used for COPD.11 Cardiovascular disease is a major comorbidity and probably the most frequent and most significant.12,13 A previous report demonstrated that the prevalence of cardiovascular disease was one of the major determinants of the overall cost of COPD.14 In the present study, ischaemic heart disease and congestive heart failure, which may directly affect mortality, were more commonly observed among COPD patients attending tertiary facilities. The reason for the greater cost of out- and in-patient
care in patients attending tertiary facilities can be partly explained by the higher rates of cardiovascular comorbidities. The number of COPD patients increased by 10.9% from 2006 to 2008, and has shown little change since then. This increase was partly attributable to a natural increase in the aging population and continued exposure to risk factors. Improved physician understanding of COPD may have contributed to the increase in the number of COPD patients until 2008, but was probably not sufficient to reach a meaningful increase in the COPD population since 2009. However, total medical costs gradually increased over the study period, mainly due to a steady increase in prescription rates for LAMA and ICSþLABA, which are more expensive than other COPD drugs. In the present study, total average direct health care costs per COPD patient were US$2800 in Korea in 2009, which are slightly higher than in Canada and the United States,15 and represent a considerable economic and social burden. The reason for the relatively high costs was not fully understood, but they are partly attributable to easy access to health care and hospitalisation. To our knowledge, this is the first study to perform a nationwide analysis of the pattern of COPD-related drug prescriptions and changes over time using a national health insurance database. The number of LAMA and ICSþLABA prescriptions was very low in primary and secondary facilities compared to tertiary facilities. However, the overall frequency of LAMA and ICSþLABA prescriptions increased steeply; in
Economic burden of COPD in Korea
particular, the use of LAMA more than doubled during the 5 years of the study. This may have been partly due to increased awareness about COPD among physicians, but was mainly due to the launch of tiotropium bromide in Korea in February 2005. Despite the increase in the number of prescriptions for LAMA, annual rates of hospitalisation and ED visits and mean days of hospitalisation per patient did not change significantly over the 5 years (data not shown). It is well known that the use of LAMA is more likely to reduce the number of exacerbations and COPD-related hospitalisations.16,17 However, in our data, the mean number of actual LAMA prescriptions per patient was only 2.03 in 2009. This might be due to a high proportion of mild COPD and undertreatment. The high cost of inhalers may have led to non-adherence in some patients.18 Another interesting finding was the popular use of methylxanthine and systemic beta-agonists throughout the study period. This reflects the underutilisation of inhaled medications in primary care and inadequate adherence to current treatment guidelines for COPD in real practice. Although the cost of inhaled medications is high, guideline-based prescription and treatment should be recommended to reduce exacerbation and improve health-related quality of life in COPD patients. The present study had several limitations. First, as the pulmonary function testing results were not available, patients enrolled in the study did not have a proven diagnosis of COPD (FEV1/FVC ratio). Second, data on smoking history and occupational or environmental exposure were not available. However, the definition of COPD was largely based on ICD-10 codes for COPD or emphysema, and it is probable that physicians attributed ICD-10 codes on the understanding that cigarette smoking is the most common risk factor for COPD. Third, although indirect cost estimations are useful in assessing the true economic and social burden of a disease, we could not estimate indirect costs such as those due to lost work and productivity. It should be noted in this regard that more than half of the total annual costs of COPD in the United States were indirect.19
CONCLUSIONS The present study provides new insight into health care use and medical costs for COPD in Korea. Changing patterns in COPD-related medication use are a useful indicator of COPD management in real practice. Our findings provide fundamental data necessary to inform COPD management policies. Training programmes for primary care physicians on early diagnosis and intervention and a state-of-the-art review of COPD management would be useful.
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Acknowledgements This study was supported by a grant from the Korea Healthcare Technology R&D Project (A102065). Conflicts of interest: none declared.
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Economic burden of COPD in Korea
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RESUME
La pr´evalence et le fardeau e´ conomique des maladies pulmonaires chroniques obstructives (BPCO) augmentent dans le monde. Cependant, on dispose de peu d’information sur l’utilisation des soins de sant´e et les couts ˆ li´es aux BPCO en Cor´ee. O B J E C T I F : Analyser l’utilisation des soins de sant´e, les couts ˆ m´edicaux et l’utilisation des m´edicaments en 2009 ainsi que les modifications des couts ˆ et du choix des m´edicaments sur 5 ans (de 2006 a` 2010). S C H E´ M A : Grace ˆ a` la base de donn´ees des services d’´evaluation de la s´ecurit´e sociale cor´eenne, les patients atteints de BPCO ont e´ t´e identifi´es en recherchant a` la fois le code ICD-10 et les m´edicaments des BPCO. R E´ S U LT A T S : Un total de 192 496 patients avec BPCO a e´ t´e identifi´e en 2009. Le cout ˆ m´edical total par patient e´ tait de 2803 6 3865 US$ et le nombre moyen de jours de CONTEXTE :
consultation et d’hospitalisation par an e´ tait respectivement de 40 6 36 et de 11 6 33 jours. La methylxanthine et les beta-agonistes syst´emiques e´ taient les m´edicaments les plus utilis´es. Cependant, la fr´equence de prescription des antagonistes muscariniques a` lib´eration prolong´ee a augment´e rapidement. Le cout ˆ total des m´edicaments li´es aux BPCO a augment´e de 33,1% en 5 ans. C O N C L U S I O N : Cette e´ tude fournit une nouvelle vision de l’utilisation des soins de sante´ et du fardeau e´ conomique des BPCO en Cor´ee. Les modifications du profil d’utilisation des m´edicaments li´es aux BPCO sont e´ galement une information importante. Elles peuvent eˆ tre une donn´ee fondamentale dans l’´elaboration d’une politique de gestion des BPCO.
RESUMEN D E R E F E R E N C I A: La prevalencia de la enfermedad pulmonar obstructiva cronica ´ (EPOC) con la carga economica ´ que impone esta´n en aumento en todo el mundo. Sin embargo, se cuenta con poca informacion ´ sobre la utilizacion ´ de los sistemas de salud en relacion ´ con la EPOC y los costos que acarrea en Corea. O B J E T I V O: Analizar la utilizacion ´ de los servicios de salud, los costos de atencion ´ m´edica y el uso de medicamentos en el ano ´ ˜ 2009 y evaluar la evolucion de los costos y el uso de medicamentos durante un per´ıodo de 5 anos ˜ (de 2006 a 2010). M E´ T O D O: Se incluyeron los pacientes con EPOC de la base de datos del Servicio Coreano de Evaluacion ´ y Revision ´ del Seguro M´edico tras una busqueda ´ por el codigo ´ del CIE-10 y por medicamentos para EPOC. R E S U LT A D O S: Se detectaron 192 496 pacientes con EPOC en el 2009. El costo m´edico total por persona fue MARCO
US$ 2803 6 3865; el promedio anual de d´ıas de consulta externa por paciente fue 40 6 36 y el de los d´ıas de hospitalizacion ´ fue 11 6 33. Los medicamentos ma´s utilizados fueron las metilxantinas y los agonistas beta sist´emicos. Sin embargo, la frecuencia de recetas de antagonistas muscar´ınicos de acci on ´ prolongada aument o´ ra´ pidamente. El costo total de los medicamentos relacionados con la EPOC revelo´ un aumento del 33,1% durante los 5 anos. ˜ ´ N: El presente estudio aporta una nueva CONCLUSIO perspectiva sobre la utilizacion ´ de la atencion ´ de salud y la carga economica ´ en relacion ´ con la EPOC en Corea. La modificacion ´ en el tipo de utilizacion ´ de los medicamentos para el EPOC es tambi´en una informaci on ´ valiosa. Estos resultados pueden fundamentar el establecimiento de las directrices del tratamiento de la EPOC.
