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Clinical, humanistic, and economic burden of chronic obstructive pulmonary disease (COPD) in Canada: a systematic review

  • Tam Dang-Tan1Email author,
  • Afisi Ismaila2, 3,
  • Shiyuan Zhang1,
  • Victoria Zarotsky4 and
  • Mark Bernauer4
BMC Research Notes20158:464

https://doi.org/10.1186/s13104-015-1427-y

Received: 31 July 2014

Accepted: 9 September 2015

Published: 21 September 2015

Abstract

Background

Chronic obstructive pulmonary disease (COPD) is a chronic, irreversible disease and a leading cause of worldwide morbidity and mortality. In Canada, COPD is the fourth leading cause of death. This systematic review was undertaken to update healthcare professionals and decision makers regarding the recent clinical, humanistic and economic burden evidence in Canada.

Methods

A systematic literature search was conducted in PubMed, EMBASE, and Cochrane databases to identify original research published January 2000 through December 2012 on the burden of COPD in Canada. Each search was conducted using controlled vocabulary and key words, with “COPD” as the main search concept and limited to Canadian studies, written in English and involving human subjects. Selected studies included randomized controlled trials, observational studies and systematic reviews/meta-analyses that reported healthcare resource utilization, quality of life and/or healthcare costs.

Results

Of the 972 articles identified through the literature searches, 70 studies were included in this review. These studies were determined to have an overall good quality based on the quality assessment. COPD patients were found to average 0–4 annual emergency department visits, 0.3–1.5 annual hospital visits, and 0.7–5 annual physician visits. Self-care management was found to lessen the overall risk of emergency department (ED) visits, hospitalization and unscheduled physician visits. Additionally, integrated care decreased the mean number of hospitalizations and telephone support reduced the number of annual physician visits. Overall, 60–68 % of COPD patients were found to be inactive and 60–72 % reported activity restriction. Pain was found to negatively correlate with physical activity while breathing difficulties resulted in an inability to leave home and reduced the ability to handle activities of daily living. Evidence indicated that treating COPD improved patients’ overall quality of life. The average total cost per patient ranged between CAN $2444–4391 from a patient perspective to CAN $3910–6693 from a societal perspective. Furthermore, evidence indicated that COPD exacerbations lead to higher costs.

Conclusions

The clinical, humanistic and economic burden of COPD in Canada is substantial. Use of self-care management programs, telephone support, and integrated care may reduce the overall burden to Canadian patients and society.

Keywords

COPDChronic obstructiveLiterature reviewBurdenBurden of illnessCanadaCostsClinicalEconomicHumanisticQuality of life

Background

Chronic obstructive pulmonary disease (COPD) is a persistent, irreversible, progressive disease exacting a heavy toll on patients and caregivers and is a leading cause of morbidity and mortality worldwide [14]. Estimates indicate that more than 10 % of the adult population are affected by COPD, and one in four adults over the age of 35 will develop COPD in their lifetime [5, 6]. In Canada, COPD is project to be the fourth leading cause of death behind heart disease, cancer and stroke and is expected to be the third leading cause of death by 2020 [3]. Exposure to environmental factors is thought to be the major underlying cause of COPD, with smoking being the most important risk factor [79]. Comorbidities, such as cardiovascular disease, are very common and are thought to contribute to the vast majority of COPD deaths [1012].

The unique features of the Canadian universal healthcare system provide different challenges for government and health care providers alike in the delivery and implementation of health services. With the substantial burden and societal importance of COPD, it is important for Canadian healthcare professionals and decision makers to remain up to date with evidence of managing and treating COPD. A sizeable body of research on the burden of COPD in Canada has been conducted in recent years; however, a systematic review of recent evidence is lacking. The overall purpose of this systematic review is to update the knowledge of the burden of COPD in Canada by summarizing the most current, evidence-based information. The specific objective is to summarize the recent literature describing the clinical, humanistic and economic burden of COPD among Canadians.

Methods

Literature search

We conducted a search of the PubMed, EMBASE, and Cochrane databases to identify original research (observational and interventional studies, burden of illness studies, and cost of illness studies) published January 2000 through December 2012 on the burden of COPD in Canada. Non-systematic review articles, letters, editorials, commentaries, studies reporting summaries of meeting proceedings or conferences, abstracts or posters presented at scientific meetings, and studies examining the efficacy or effectiveness of specific pharmacotherapy interventions were not included. Each search was conducted using controlled vocabulary and key words and was limited to articles published in English, studies conducted with Canadian data, and studies involving humans. Additional articles were identified and added to each review through a review of the bibliographies of included articles and if identified in the other literature search (i.e. article with economic data found in humanistic literature search).

Study selection

Titles and abstracts of articles identified were carefully screened in the initial review for relevance to the topic by a single reviewer. Articles were selected for inclusion based on predefined acceptance criteria, which included relevant patient population (i.e., adults/children diagnosed with COPD), study design [randomized controlled trial (RCT), observational study, systematic review/meta-analyses] and outcome measures (healthcare resource utilization, quality of life, healthcare costs). Complete articles were obtained for any article that categorized as ‘included’ or ‘unsure’ after the title and abstract review. All ‘unsure’ articles were then reviewed to make a final determination of inclusion or exclusion. A second, independent reviewer performed a check on a random sample of 20 % of the articles with discrepancies resolved through consensus. Articles identified as potentially relevant were obtained in full text for further evaluation.

Data abstraction

Data abstraction forms were designed a priori. For articles that met predefined inclusion/exclusion criteria, key outcomes were abstracted and tabulated in summary tables. Key outcomes extracted included: emergency department visits, hospitalization and office visits in the clinical burden literature; quality of life measures in the humanistic burden literature; patient and population costs in the economic burden literature. In the economic burden section, reported costs were inflated to 2012 Canadian dollars using the Consumer Price Index from Statistics Canada (http://www.statcan.gc.ca). A second, independent reviewer performed a check on a random sample of the data abstracted from 20 % of the articles.

Quality assessment

Quality was assessed by using internationally recognized methodological checklists from the National Institute for Health and Care Excellence (NICE) Guidelines Manual for RCT [13], the strengthening the reporting of observational studies in epidemiology (STROBE) statement [14] for observational studies, and the PRISMA checklist for systematic reviews and meta-analyses [15]. The NICE RCT checklist provides an assessment of potential bias in 4 categories: selection, performance, attrition and detection. The STROBE checklist contains 22 items that assess completeness of reporting in observational studies and the 27-item PRISMA checklist provides a similar assessment for systematic reviews and meta-analyses. The information collected in these checklists enabled a decision to be made about the eligibility of the studies for inclusion in this project. A second, independent reviewer performed a quality review check on a random sample of 20 % of the articles.

Results

Literature search

A total of 495 studies were identified by the clinical and economic burden literature searches with 58 studies being suitable for inclusion (Fig. 1). The 58 studies included: 3 systematic review/meta-analyses, 5 RCTs, and 27 cohort, 18 cross-sectional, and 5 case–control studies. A total of 477 studies were identified by the humanistic burden literature searches of which 12 studies were ultimately included (Fig. 2). The study designs of the 12 included articles were 6 RCTs, 4 cross-sectional and 2 case–control studies.
Fig. 1

Clinical/economic burden literature search results

Fig. 2

Humanistic literature search results

Quality assessment

The clinical and economic burden literature included 3 systematic review/meta-analyses which met most of the PRISMA checklist criteria [1618]. The criteria that were not met included: no description of methods for combining studies (100 %), not addressing risk of bias across studies (67 %) or individual studies (33 %) and not describing study limitations (67 %). Of the 5 RCTs appraised using the NICE RCT methodology checklist, most were rated as having a low risk of bias; however, a high risk of attrition bias was noted for three studies [1921]. Lastly, the 50 remaining studies were assessed using the STROBE checklist. Many of the cohort studies did not indicate the study design (36 %), lacked reporting sensitivity or sub-group analyses (71 %), and missing or follow-up data was infrequently addressed (68 and 39 % respectively). The methodological limitations identified for the cross-sectional and case–control studies were very similar.

The humanistic burden literature included a total of 6 RCTs which were appraised by the NICE RCT methodology, all of which had an overall low risk of bias. The remaining 6 studies met most of the STROBE criteria; however, only 2 of the 6 studies adequately described the study setting [22, 23], 2 studies discussed efforts to address sources of bias [22, 24], and there was an overall lack of reporting on how missing data was addressed as well as sub-group and sensitivity analysis [2327].

Clinical burden evidence results

Overview

Of the 57 articles with clinical burden data (Tables 1, 2 and 3), the primary data source for 60 % of the studies (retrospective cohort and cross-sectional designs) was the provincial healthcare databases containing hospital records and pharmaceutical claims. The time frame of the included studies varied based on the study design. In general, the prospective designed studies included a much shorter time frame than systematic reviews or retrospective database analyses which often spanned decades.
Table 1

Summary of emergency department visit evidence

References

Geographic region (study years)

Patients

Arms or cohorts

Patients with ED visits, # (%)

# of ED visits

Mean annual ED # visits/patient

Polisena et al. [17]

Calgary (1998–2009)

≥60 years (mean age)

Telephone support

40.6 % of patients

 

0.1 visits

Usual care

63.15 % of patients

 

0.4 visits

Labrecque et al. [29]

Montreal (2004)

40–75 years, stable COPD

Self-management education (n = 57)

  

Pre-index 1.1 visits

Post-index 0.2 visits

Usual care (n = 45)

  

Pre-index 0.4 visits

Post-index 0.4 visits

Chapman et al. [1], Wouters et al. [37]

Canada (1 year study)

Diagnosed/undiagnosed COPD patients

All patients (n = 401)

70 patients (17.5 %)

151 visits

0.38 visits

Moullec et al. [28]

Montreal (2004–2006)

Montreal hospital patients

Integrated care (n = 96)

Prior year 27 (28.1 %), Post-Index 28 (29.2 %)

 

Pre and Post-Index 0.5 visits

Usual care (n = 93)

Prior year 27 (29.0 %), Post-Index 26 (28.0 %)

 

Pre and Post-Index 0.5 visits

Bischoff et al. [39]

 

COPD patients, ≥40 years

All patients (n = 119)

  

Preceding year 0.65 visits

Rowe et al. [34]

US, Canada

≥55 year, stable COPD

Canadian patients (n = 63)

  

Previous year 1.0 visits

Tsai et al. [45]

US, Canada

≥55 year, stable COPD

Underweight (BMI <18.5, n = 50)

  

Previous year 2.0 visits

Normal weight (BMI 18.5–24.9, n = 148)

  

Previous year 1.0 visits

Overweight (BMI 25–29.9, n = 105)

  

Previous year 1.0 visits

Obese (BMI ≥ 30, n = 92)

  

Previous year 1.0 visits

Sin et al. [38]

(1992–1997)

age ≥65 years, discharged diagnosis of COPD

No inhaled corticosteroid (n = 11,139)

  

Preceding year 1.2 visits

Inhaled corticosteroid (n = 11,481)

  

Preceding year 1.6 visits

Johnston et al. [32]

Hamilton, Ontario (Dec 2006–Jan 2007)

≥40 year, COPD of mixed severity

GOLD stratum 0 (n = 39)

  

Previous year 1.6 visits

GOLD stratum 1 and 2 (n = 31)

  

Previous year 1.4 visits

GOLD stratum 3 and 4 (n = 44)

  

Previous year 1.8 visits

Wang et al. [35]

Montreal (2 year study)

≥40 years, Moderate-severe COPD hospitalized

All Patients (n = 282)

54 patients (19.1 %)

99 visits

1.82 visits

Rowe et al. [30], Rosychuk et al. [31]

Alberta (1999–2005)

≥55 years

All patients (38,638)

38,638 patients

85,330 visits

2.2 visits

Golmohammadi et al. [36]

Edmonton (2000–2002)

>45 years

Rehab program: DSS-S1 (n = 31)

  

Pre 42.1 visits/100 pt-years

Post 13.6 visits/100 pt-years

Rehab program: DSS-S2A (n = 78)

  

Pre 57.0 visits/100 pt-years

Post 44.8 visits/100 pt-years

Rehab program: DSS-S2B (n = 51)

  

Pre 29.5 visits/100 pt-years

Post 16.3 visits/100 pt-years

Rehab program: DSS-S3 (n = 41)

  

Pre 41.0 visits/100 pt-years

Post 54.4 visits/100 pt-years

Stephenson et al. [40]

Ontario (2003–2010)

>66 years, Concomitant dementia and COPD

ChEI users (n = 7166)

Baseline 538 (7.5 %)

  

ChEI non-users (n = 7166)

Baseline 517 (7.2 %)

  

Blais et al. [41]

Quebec (Feb 2003–Jan 2007)

≥40 years

Budesonide/formoterol (n = 1131)

10.3 % of patients

182 visits

 

Propionate/salmeterol (n = 1131)

13.1 % of patients

256 visits

 

Gershon et al. [42]

Ontario (2003–2007)

≥66 years

Long-acting anticholinergic (n = 28,563)

12.2 % of patients

  

Long-acting beta-agonist (n = 17,840)

11.7 % of patients

  

FitzGerald et al. [43]

Canada (1 year study)

≥40 year

All patients (n = 609), all exacerbation (n = 691)

 

193 visits

 

Patients with exacerbations (n = 278)

111 patients (39.9 %)

  

Sedeno et al. [21]

 

COPD patients

Usual care (n = 81)

54.4 % patients

  

Self-management group (n = 85)

29.9 % patients

  

Bourbeau et al. [44]

 

Advanced COPD, ≥1 hospitalization for exacerbation in last year

Usual care (n = 95)

63.2 % patients

  

Self-management care (n = 96)

40.6 % patients

  

Mittmann et al. [3]

Canada

Moderate and severe COPD exacerbations

All patients (n = 609), all exacerbation (790 exacerbations)

 

245 visits

 

Moderate exacerbation (639 exacerbations)

 

105 visits

 

Severe exacerbation (151 exacerbations)

 

140 visits

 

Beauchesne et al. [77]

(1995–2004)

COPD patients

Home management program (n = 152)

 

29 visits

 

Dormuth et al. [60]

British Columbia

≥45 years, 2.5-year period after public coverage

Predicted use

 

6658 visits

 

Observed use

 

7434 visits

 
Table 2

Summary of hospitalization evidence

References

Geographic region (study years)

Patients

Arms or cohorts

Hospitalization, # or  % patients

# of hospital visits

Mean annual hospital # visits/patient

Tsai et al. [45]

US, Canada

≥55 year, stable COPD

Underweight (BMI <18.5, n = 50)

  

Prior year 0 visits

Normal weight (BMI 18.5–24.9, n = 148)

  

Prior year 0 visits

Overweight (BMI 25–29.9, n = 105)

  

Prior year 0 visits

Obese (BMI ≥ 30, n = 92)

  

Prior year 0 visits

Rowe et al. [34]

US, Canada

≥55 year, stable COPD

Canadian patients (n = 63)

  

Prior year 0 visits

Johnston et al. [32]

Hamilton, Ontario (Dec 2006–Jan 2007)

≥40 year, COPD of mixed severity

GOLD stratum 0 (n = 39)

 

1

Prior year 1.3 visits

GOLD stratum 1 and 2 (n = 31)

 

3

Prior year 1.2 visits

GOLD stratum 3 and 4 (n = 44)

 

7

Prior year 1.5 visits

Labrecque et al. [29]

Montreal (2004)

40–75 years, stable COPD

Self-management (n = 57)

  

Prior year 0.7 visits

Post index 0.3 visits

Usual care (n = 45)

  

Prior year 0.5 visits

Post index 0.5 visits

Moullec et al. [28]

Montreal (2004–2006)

Montreal hospital patients

Integrated care (n = 96)

Prior year 96

Post-index 38

 

Prior year 1.3 visits

Post index 0.7 visits

Usual care (n = 93)

Prior year 69

Post-index 55

 

Prior year 1.5 visits

Post-index 1.3 visits

Ohinmaa et al. [46]

Alberta

Adult from Canadian Community Health Survey

20–44 years

  

0 visits

45–64 years

  

3.45 visits

>65 years

  

5.19 visits

Blais et al. [41]

Quebec (Feb 2003–Jan 2007)

≥40 years

Budesonide/formoterol (n = 1131)

8.6 %

130

0.11 visits

Propionate/salmeterol (n = 1131)

12.4 %

233

0.21 visits

FitzGerald et al. [43]

Canada (1 year study)

≥40 year,

All patients (n = 609)

75

112

0.2 visits

Patients with exacerbations (n = 278)

 

75

1.5 visits

Chapman et al. [1], Wouters et al. [37]

Canada (1 year study)

Diagnosed/undiagnosed COPD patients

All patients (n = 401)

Prior year 14 %

 

0.32 visits (0 visits/year 1999–2005)

Wong et al. [47]

Vancouver, British Columbia (winter 2006–2007)

Admitted St. Paul’s Hospital with AECOPD diagnosis

Entire population (n = 109)

  

3.3 visits (6-month readmission rate)

Beaulieu et al. [48]

 

Moderate-severe COPD

Self-administered prescription (n = 46)

  

0.3 visits (prior 6-months)

Control (n = 43)

  

0.5 visits (prior 6-months)

Sin et al. [38]

(1992–1997)

age ≥65 years, discharged diagnosis of COPD

All Patients (n = 22,620)

5654 (25 % repeat hospitalization)

  

Chen et al. [50]

(First admission 1999–2000)

COPD In-patients, ≥40 years

Entire population (n = 108,726)

49.1 % rehospitalization

  

Huiart et al. [51]

(1990–1997, 1st COPD treatment)

≥55 years, first treatment of COPD

All (n = 5648)

1027

2326

101.4 visits/1000 PY

Female (n = 2606)

399

812

74.3 visits/1000 PY

Male (n = 3042)

673

1514

126.1 visits/1000 PY

Sedeno et al. [21]

 

COPD patients

Usual care (n = 81)

36.3 %

  

Self-management group (n = 85)

17.2 %

  

Chen et al. [76]

 

General population, broad (B) and narrow (N) defined cases for COPD hospitalization

All (n = 6,099,756)

B = 257,604, N = 85,189

 

B = 42.2, N = 14.0/1000 PY

Age 55–59 (n = 1,332,254)

B = 16,671, N = 5129

 

B = 12.5, N = 3.8/1000 PY

Age 60–64 (n = 1,207,873)

B = 26,904, N = 8579

 

B = 22.3, N = 7.1/1000 PY

Age 65–69 (n = 1,121,508)

B = 40,823, N = 13,404

 

B = 36.4, N = 12.0/1000 PY

Age 70–74 (n = 963,007)

B = 51,782, N = 17,310

 

B = 53.8, N = 18.0/1000 PY

Age 75–79 (n = 683,520)

B = 49,788, N = 16,983

 

B = 72.8, N = 24.8/1000 PY

Age 80–84 (n = 450,458)

B = 40,666, N = 13,844

 

B = 90.3, N = 30.7/1000 PY

Age 85–89 (n = 227,533)

B = 21,676, N = 7,046

 

B = 95.3, N = 31.0/1000 PY

Age 90+ (n = 113,603)

B = 9294, N = 2894

 

B = 81.8, N = 25.5/1000 PY

Tu et al. [78]

 

Active smoking adults, ≥15 years of age

   

167 visits (predicted, linear regression)

Curkendall et al. [79]

(1997–2000)

≥40 years, COPD diagnosed with ≥2 bronchodilators within 6-months

COPD (n = 11,493)

  

598.36/1000 PY

CV related; 109.5/1000 PY

Controls (n = 22,986)

  

221.23/1000 PY

CV related; 44.66/1,000 PY

Mittmann et al. [3]

Canada

Moderate and severe COPD exacerbations

All exacerbations (n = 609)

 

151

 

Moderate exacerbation

 

140

 

Severe exacerbation

 

151

 

Mancini et al. [53]

 

COPD patients

Coronary revascularization (n = 946)

Prior year 2.6–5.9 %

  

Without MI (n = 18,774)

Prior year 1.6–7.3 %

  

Gonzalez et al. [80]

 

>66 years, received ≥3 respiratory medications

Women (n = 19,260)

Prior year 2.7 %

  

Men (n = 23,893)

Prior year 2.6 %

  

Macie et al. [81]

Manitoba (1997–2000)

Drug claim for obstructive airways disease

All recipients (n = 6,041)

3.2 %

  

Control (n = 60,410)

5.2 %

  

Ernst et al. [82]

 

Hospitalized with Pneumonia

Case (n = 23,942)

14.5 %

  

Control (n = 95,768)

3.6 %

  

Chan et al. [20]

 

COPD Diagnosis

Tiotropium (n = 608)

8.4 %

  

Placebo (n = 305)

8.2 %

  

Gershon et al. [42]

Ontario (2003–2007)

≥66 years

Long-acting anticholinergic (n = 28,563)

33.3 %

  

Long-acting beta-agonist (n = 17,840)

30.7 %

  

Monfared et al. [83]

(1990–1996)

Elderly COPD patients

RAMQ database (n = 1233)

32.7 %

  

MED-ECHO database (n = 1206)

32.0 %

  

Polisena et al. [17]

Calgary (1998–2009)

≥60 years (mean age)

Telephone support

32–46 %

  

Usual Care

51–66 %

  

Goodridge et al. [52]

(Deceased in 2004)

COPD or lung cancer death

All patients (n = 1098)

80.4 %

  

Aaron et al. [56]

Canada (1995–2004)

COPD patients

Tiotropium + Plac (n = 156)

62

  

Tiotropium + Salmeterol (n = 148)

48

  

Tiotropium + Fluticasone-Salmeterol (n = 145)

41

  

Benayoun et al. [84]

(1996–1997)

>45 years, initiating treatment with combination inhaler

Combined Bronchodilator (n = 641)

Prior year 202

  

Double-users (n = 411)

Prior year 279

  

Stephenson et al. [40]

Ontario (2003–2010)

>66 years, Concomitant dementia and COPD

ChEI users (n = 7166)

Prior year 469

  

ChEI non-users (n = 7166)

Prior year 403

  

Bourbeau et al. [85]

 

≥55 years, without asthma initiating COPD treatment

Case (n = 843)

Current ICS use 275, past user 141

  

Control (n = 11,030)

Current ICS use 2994, past user 1357

  

Beauchesne et al. [77]

(1995–2004)

COPD patients

Home management (n = 152)

 

100

 

Bourbeau et al. [44]

 

Advanced COPD, ≥1 hospitalization for exacerbation in last year

Usual care (n = 95)

 

Prior, 152

Year 1, 118

 

Self-management care (n = 96)

 

Prior year, 158

Year 1, 71

 

Disano et al. [86]

(2003–2006)

Ambulatory care COPD

Low SES

 

381a

 

Average SES

 

210a

 

High SES

 

129a

 

Keenan et al. [87]

London

COPD with exacerbation at emergency room

All patients (n = 25)

 

355 (over 3 years 2 months)

 

Dormuth et al. [60]

British Columbia

≥45 years, 2.5-year period after public coverage

Predicted use

 

42,735

 

Observed use

 

44,007

 

PY patient years

aRates per 100,000 people

Table 3

Summary of physician visit evidence

References

Geographic region (study years)

Patients

Arms or cohorts

Physician visits, # or  % patients

# of physician visits

Mean annual physician visits, # visits/patient

Blais et al. [41]

Quebec (Feb 2003–Jan 2007)

≥40 years of age

Budesonide/formoterol (n = 1131)

58.5 %

1956

1.73 visits

Propionate/salmeterol (n = 1131)

59.7 %

1779

1.57 visits

Ohinmaa et al. [46]

Alberta

Adult from Canadian Community Health Survey

20–44 years

  

6.52 visits

45–64 years

  

5.63 visits

>65 years

  

8.10 visits

Goodridge et al. [52]

(Deceased in 2004)

COPD or lung cancer death

All patients (n = 1098)

59.8 % (>24 visits within 12 months of death)

 

28.0 visits (12 months prior to death)

Polisena et al. [17]

Calgary (1998–2009)

≥60 years of age

Telephone support

  

PCP; 0.48 vs. 1.18 UC

Office visits; 5.0 vs. 6.0 UC

Home telemonitoring

  

Office visits; 3.2 vs 2.3 UC

Rowe et al. [34]

US, Canada

≥55 year, stable COPD

Canadian patients (n = 63)

  

0 urgent clinic visits, prior-year

US patients (n = 334)

  

0 urgent clinic visits, prior-year

Sin et al. [38]

(1992–1997)

age ≥65 years, discharged diagnosis of COPD

No-inhaled corticosteroid (n = 11,139)

  

4.1 visits, prior year

Inhaled corticosteroid (n = 11,481)

  

4.1 visits, prior year

Mancini et al. [53]

 

COPD patients, with CV revascularization and without MI newly treated with NSAIDS

High-risk cohort cases (n = 946)

  

20 visits, prior year

High-risk controls (n = 18,774)

  

19 visits, prior year

Low-risk cohort cases (n = 4907)

  

5 visits, prior year

Low-risk controls (n = 98,097)

  

5 visits, prior year

Beaulieu et al. [48]

 

Moderate-severe COPD

Self-administered Rx (n = 46)

  

0.8 visits (prior 6-months)

Control (n = 43)

  

0.7 visits (prior 6-months)

Johnston et al. [32]

Hamilton, Ontario (Dec 2006–Jan 2007)

≥40 year, COPD of mixed severity

GOLD stratum 0 (n = 39)

 

9

 

GOLD stratum 1 and 2 (n = 31)

 

15

 

GOLD stratum 3 and 4 (n = 44)

 

15

 

Bourbeau et al. [44]

 

Advanced COPD, ≥1 hospitalization for exacerbation in last year

Usual Care (n = 95)

 

Scheduled 309

Unscheduled 112

 

Self-management care (n = 96)

 

Scheduled 354

Unscheduled 46

 

Sedeno et al. [21]

 

COPD patients

Usual care (n = 81)

30.9 %

  

Self-management group (n = 85)

8.2 %

  

Bischoff et al. [39]

 

COPD patients, ≥40 years

All patients (n = 217)

Unscheduled Visits; 70

  

Chapman et al. [1], Wouters et al. [37]

Canada, 7 countries North America and Europe (1 year study)

Diagnosed/undiagnosed COPD patients

All patients (n = 401)

Scheduled PCP; 225

Unscheduled PCP; 175

Scheduled 1506

Unscheduled 175

 

Macie et al. [81]

Manitoba (1997–2000)

Drug claim for obstructive airways disease

All recipients (n = 6041)

0–1 visit; 18.0

2–3 visits; 23.0 %

4–9 visits; 36.6 %

≥10 visits; 22.4 %

  

Control (n = 60,410)

0–1 visit; 32.8 %

2–3 visits; 24.0 %

4–9 visits; 29.1 %

≥10 visits; 14.1 %

  

Disano et al. [86]

Canada (fiscal years 2003–04, 2004–05 and 2005–06)

Children under 20 years, fiscal years 2003–04, 2004–05 and 2005–06

All (46,173)

48 %

  

Underweight (BMI <18.5)

42 %

  

Normal weight (BMI 18.5–24.9)

56 %

  

Overweight (BMI 25–29.9)

55 %

  

Obese (BMI ≥ 30)

32 %

  

FitzGerald et al. [43]

Canada (1 year study)

≥40 years of age

Patients with exacerbations (n = 278)

255

  

Stephenson et al. [40]

Ontario (2003–2010)

>66 years, Concomitant dementia and COPD

ChEI users (n = 7166)

1 visit, 36; ≥2 visits 7062

  

ChEI non-users (n = 7166)

1 visit, 131; ≥2 visits 6940

  

Dormuth et al. [88]

British Columbia (1997–2004)

≥65 years of age

Policy Group (n = 19,985)

6-months prior/follow-up

0–4 visits; 4610

≥5 visits; 15,375

  

Pre-policy group (n = 17,335)

6-months prior/follow-up

0–4 visits; 4439

≥5 visits; 12,896

  

Mittmann et al. [3]

Canada

Moderate and severe COPD exacerbations

All exacerbations (n = 609)

 

618

 

Moderate exacerbation

 

574

 

Severe exacerbation

 

44

 

Sin et al. [89]

Alberta (1996–1997)

General Population (2.8 million)

Aboriginals

 

15,712

 

Non-aboriginals

 

275,134

 

Dormuth et al. [60]

British Columbia

≥45 years, 2.5-year period after public coverage

Predicted use

 

2,073,233 (over 2.5 years)

 

Observed use

 

2,094,360 (over 2.5 years)

 

Rowe et al. [30]

Alberta (1999–2005)

≥55 years at time of ED visit

All Patients (n = 7302)

 

GP 107,405

Int Med 13,907

Resp Med 5287

 

Moineddin et al. [90]

Ontario (1992–2002)

All patients with at least 1 primary care visit

  

4,662,735 over 11 years

 

PY patient years, PCP primary care physician, UC usual care, Rx prescription

Emergency department (ED) visits

Emergency department visits were reported as an outcome in 23 out of the 58 studies (Table 1). A number of studies reported the mean number of emergency department visits which ranged from 0.1 to 2.20 per year [1, 17, 2839]. Eleven studies reported that 7.2–63.2 % of patients with COPD visited the emergency department [1, 17, 21, 28, 30, 35, 4044]. Johnston [32] reported the mean annual number of ED visits by disease severity. The instrument used to assess disease severity was developed by the global initiative for chronic obstructive lung disease (GOLD) and categorizes patients from mild to very severe in 4 levels (GOLD 1–4 stratum). The mean number of annual ED visits ranged from 1.4 (GOLD stratum 1 and 2) to 1.8 (GOLD stratum 3 and 4) in COPD patients with an exacerbation [32].

Three studies reported how different pre/post interventions affected ED visits in COPD patients. Overall ED visits were less in COPD patients with self-management education or self-care management programs; however, integrated care appeared to provide no benefit on the annual mean number of ED visits [28, 29, 44].

Hospitalization

Hospitalization was reported as an outcome in 38 of the 58 studies (Table 2). The rates were reported as either pre- or post- index hospitalizations. The mean number of annual hospital visits per COPD patient per year ranged from: 0–1.5 pre-index to 0–5.19 post-index [1, 28, 29, 32, 34, 41, 43, 4548]. Three studies reported the rates of hospitalization according to disease severity and/or COPD exacerbations and found higher rates of hospitalization in more severe patients (GOLD stratum 3 or 4) and those with more severe exacerbations [3, 32, 43]. Hospital readmission rates varied between three studies with Sin [49] reporting a rate of 25 % for COPD patients ≥65 years of age, Chen [50] reporting a rate of 49.1 % in patients ≥40 years of age, and Wong [47] reporting 3.3 mean annual number of hospital readmissions in patients with a diagnosis of AECOPD.

The relationship of COPD hospitalization rates to patient demographic characteristics was examined in three studies. A higher rate of hospitalization was found in male COPD patients [126.1/1000 patient years (PY)] than females (74.3/1000 PY) and in those >65 years of age (5.19 visits/patient annually) versus those 45–64 years of age (3.45 visits/patient annually) [46, 51]. One study found that COPD patients’ body mass index (BMI) status had no effect on hospitalization rates [45].

Lastly, three studies examined the effects of different interventions on hospitalization rates in COPD patients. Moullec [28] found that integrated care (a combination of self-management education and case management) resulted in a decreased mean number of hospitalizations compared to usual care. Lebrecque [29] and Sedeno [21] found that self-management interventions also reduced hospitalizations compared to usual care.

Physician visits

A total of 24 studies reported the rate of physician visits for COPD (Table 3). The annual rate of physician visits post-index for COPD patients ranged between 1.57 and 28 visits annually [41, 46, 52]. Two studies found that elderly COPD patients (>65 years) had high rates of physician visits compared to younger patients (from 4.1 to 8.1 visits/year) [38, 46], one study found those at high risk for CV-related comorbidities had higher physician visit rates compared to those with low risk (20 vs. 5 visits per year) [53], and one study reported that COPD patients diagnosed with GOLD stratum 1–4 had a higher number of exacerbations requiring a physician visit compared to those with GOLD stratum 0 (15 vs. 9 visits, respectively) [32]. Goodridge [52] found the highest rate of physician visits for COPD patients was within 12 months of death (28 visits/year) and Rowe [34] found that Canadian and US stable COPD patients had similar mean annual urgent clinic visit rates. Lastly, two studies found that self-management interventions reduced the number of unscheduled physician visits [21, 44] and a review article found a reduction in the number of annual physician visits for patients receiving telephone support [17].

Humanistic burden evidence

Overview

A total of 12 studies were identified describing the humanistic burden by measuring the effect of COPD on a patient’s health-related quality of life (HRQoL) and physical activity (Table 4). Study timeframes were not reported in three studies and variation was found in the definition of COPD across all studies. With regard to the type of HRQoL instruments used, 4 studies [22, 25, 54, 55] reported outcomes for the 36-item short form health survey (SF-36) and 5 studies reported results for The St. George Respiratory Questionnaire (SGRQ) [20, 22, 27, 54, 56]. Other scales that were used to assess HRQoL were the chronic respiratory disease (CRD) Index Questionnaire, the sickness impact profile (SIP) and the Chronic Respiratory Questionnaire (CRQ).
Table 4

Summary of humanistic burden evidence

References/study period

Patient group

N

Scale

Baseline score, mean (SD)

Endpoint score, mean (SD)

Change from baseline, mean (SD)

SF-36 score

 Appleton et al. [54]/November 1999–September 2001

Salmeterol

172

PH

36.5 (10.0) [N = 146]

37.1 (10.5) [N = 131]

0.3 (7.7) [N = 146]; mean difference vs placebo: 0.30; 95 % CI (−1.3, 1.9)

ME

49.3 (10.8) [N = 146]

50.0 (10.5) [N = 131]

1.1 (10.0) [N = 146]; mean difference vs placebo 0.03; 95 % CI (−1.9, 1.9)

Placebo

176

PH

36.1 (9.5) [N = 156]

36.8 (10.3) [N = 144]

0.1 (6.4) [N = 156]

ME

48.8 (11.0) [N = 156]

50.3 (10.6) [N = 144]

1.1 (9.1) [N = 156]

 HajGhanbari et al. [25]/study period not reported

COPD patients

47

PH

 

35.2 (1.7) p = 0.000; AMD vs control: 16.9

 

ME

 

42.0 (1.8) p = 0.000; AMD vs control: 12.8

 

Healthy controls

47

PH

 

52.0 (1.3)

 

ME

 

54.7 (1.30)

 

 Moullec et al. [22]/Apr 2004–May 2006

Usual care

50

PH

37 (10)

  

ME

47 (12)

  

Intervention

60

PH

35 (8) p = 0.33

  

ME

45 (12) p = 0.26

  

 Lacasse et al. [55]/12 weeks

Paroxetine

12

PH

18.6 (10.0)

  

MH

53.1(23.2)

  

Placebo

11

PH

19.0 (9.9); p = 0.9

  

MH

58.0 (16.8); p = 0.4

  

SGRQ scores

 Appleton et al. [54]/November 1999–September 2001

Salmeterol

172

T

46.2 (18.0) [N = 150]

41.6 (19.0) [N = 124]

−2.9 (11.1) [N = 150]

S

59.6 (18.4) [N = 150

55.4 (19.7) [N = 124]

−3.0 (15.8) [N = 150]

A

61.6 (21.9) [N = 150

53.3 (23.8) [N = 124]

−5.9 (15.4) [N = 150]

I

33.5 (20.7) [N = 150]

30.6 (20.0) [N = 124]

−1.2 (13.6) [N = 150]

Placebo

176

T

46.8 (16.6) [N = 157]

44.7 (18.6) [N = 139]

−1.3 (10.3) [N = 157]

S

56.7 (19.6) [N = 157]

57.3 (21.6) [N = 139]

1.4 (15.5) [N = 157]

A

62.7 (18.9) [N = 157]

59.7 (22.4) [N = 139]

−3.0 (15.0) [N = 157]

I

34.8 (18.9) [N = 157]

32.4 (20.3) [N = 139]

−1.2 (11.5) [N = 157]

 Aaron et al. [56]/October 2003–January 2006

Tiotropium + placebo

156

T

  

−4.5

S

   

A

   

I

   

Tiotropium + salmeterol

148

T

  

−6.3, p = 0.02

S

   

A

   

I

   

Tiotropium + fluticasone/salmeterol

145

T

  

−8.6, p = 0.01

S

   

A

   

I

   

 Chan et al. [20]/1 year

Tiotropium

608

T

 

40.9

 

S

 

44.4

 

A

   

I

 

28.5

 

Placebo

305

T

 

43.7, p < 0.01

 

S

 

49.3, p < 0.01

 

A

   

I

 

31.3, p < 0.01

 

 Low et al. [27]/study period not reported

Patient

67

T

 

 

S

 

57.68 (24.71) [N = 66]; mean difference vs spouse: 1.73; p = 0.497

 

A

 

70.42 (17.44) [N = 67]; mean difference vs spouse: −0.21; p = 0.771

 

I

 

41.05 (22.83) [N = 66]; mean difference vs spouse: 5.6; p = 0.002

 

Spouse

67

T

 

 

S

 

59.41 (23.05) [N = 65]

 

A

 

70.21 (18.72) [N = 66]

 

I

 

47.29 (23.12) [N = 65]

 

 Moullec et al. [22]/Apr 2004–May 2006

Usual care

50

T

49 (18)

  

S

55 (16)

  

A

66 (23)

  

I

38 (20)

  

Intervention

60

T

48 (16), p = 0.72

  

S

54 (18), p = 0.74

  

A

65 (20), p = 0.85

  

I

37 (19), p = 0.72

  

Chronic Respiratory Questionnaire Scores (CRQ)

 Lacasse et al. [55]/12 weeks

Paroxetine

12

TG

   

D

3.4 (0.9), p = 1.0

  

E

3.5 (0.9), p = 0.8

  

M

4.3 (1.0), p = 0.2

  

F

3.6 (0.8), p = 0.3

  

Placebo

11

TG

  

D

3.4 (0.6)

  

E

3.7 (1.0)

  

M

4.9 (0.9)

  

F

3.2 (1.1)

  

 Bourbeau et al. [57] 6 months

Budesonide

39

TG

  

D

19.9 (6.2)

 

−1.8 (−3.9 to 0.2)

E

37.9 (6.9)

 

−1.9 (−5.3 to 1.4)

M

21.4 (4.2)

 

−0.5 (−2.4 to 1.4)

F

20.7 (3.6)

 

−3.0 (−4.9 to −1.2)

Placebo

40

TG

 

D

19.5 (5.8)

 

−0.5 (−2.3 to −1.3)

E

36.2 (9.6)

 

−0.6 (−3.4 to 2.2)

M

21.7 (5.8)

 

−1.3 (−3.0 to 0.5)

F

19.3 (5.6)

 

−1.4 (−3.1 to 0.3)

 Leigh et al. [24]/4-week treatment period

Overall population

40

TG

17.5 (3.6)

Post-PB: 18.1 (3.5)

Post-BDN: 19.4 (3.4)

Post-PDN: 21.0 (3.4)

 

D

3.7 (1.0)

Post-PB: 3.9 (0.9)

Post-BDN: 4.4 (1.1)

Post-PDN: 4.6 (1.3)

 

E

   

M

   

F

   

Physical activity

 Vozoris et al. [23]/1994–2007

Obese COPD patients

858

Inactivitya; restricted activitya

Inactive: 68 % patients

Activity restriction: 72 % patients

  

Non-obese COPD patients

2611

Inactivitya; restricted activitya

Inactive: 60 % patients

Activity restriction: 60 % patients

  

 Rocker et al. [26]. Study period not reported

Severe, stable COPD patients

8

Palliative performance scale

Scores ranged from 50 to 70 %

  

A activity score, AMD absolute mean difference, BDN budesonide, D dyspnea, E emotional function, F fatigue, M mastery, ME Mental Health summary score, PB placebo, PDN prednisone, PH Physical Health summary score, S symptoms score, T total score, TG total (Global) score, I impact score

aCanadian Fitness and Lifestyle Research Institute defined Inactivity as total daily energy expenditure value of < 1.5 kcal/kg/day; restricted activity: sometimes or often had difficulty with simple activities such as walking, climbing stairs, and bending

Sf-36

Of the 4 studies reporting SF-36 evidence, one study found that COPD patients receiving salmeterol did not experience significant improvement in their SF-36 mental or physical health summary scores compared to baseline [54]. In contrast, a case–control study reported an absolute mean difference of 16.9 in the SF-36 physical health summary score and 12.8 in the mental component score for COPD patients compared to healthy controls. The study also indicated a significantly worse (p < 0.001) level of functioning for patients with COPD [25].

St George’s Respiratory Questionnaire (SGRQ)

Four of the five studies reporting SGRQ data compared an intervention to placebo or usual care in a COPD population [20, 22, 54, 56], while one study reported data for COPD patients versus their spouses [27]. Three RCTs found pharmaceutical agents (tiotropium, salmeterol, tiotropium plus salmeterol and tiotropium plus fluticasone/salmeterol) significantly improved patients’ quality of life as measured by the SGRQ score [20, 54, 56]. Of the remaining two studies, one cross-sectional survey found a significant mean difference (5.6, p = 0.002) for the SGRQ impact of disease scores between COPD patients and their non-COPD spouse [27] and a prospective, observational study reported no significant differences in SGRQ scores at baseline between the self-management education program and usual care groups [22].

Chronic Respiratory Questionnaire (CRQ)

Three studies used the CRQ to assess the quality of life of COPD patients utilizing different pharmaceutical interventions (paroxetine, budesonide, prednisone). Of the three studies, paroxetine (CRQ emotional function domain) and inhaled corticosteroids (budesonide) were found to produce significant improvements in patients’ quality of life; however, inhaled corticosteroids (even in ‘high’ doses) did not appear to provide significant HRQoL improvement over that achieved with oral prednisone [24, 55, 57].

Miscellanous HRQoL instruments

Several studies utilized additional HRQoL instruments to assess the quality of life of COPD patients. A study by HajGhanbari [25] found that pain severity [measured by the McGill Pain Questionnaire (MPQ) and brief pain inventory scale (BPI)] showed moderate to strong negative correlations to the physical component score of the SF-36 (−0.45, −0.61, −0.70, respectively; p < 0.001). In addition, a cross-sectional survey study using the SIP found significant differences in the mean score between patients’ and healthy spouses’ ratings of the SIP physical score (p = 0.009), but non-significant differences in psychosocial score (p = 0.497) [27]. Finally, a single RCT conducted by Aaron [58] using the chronic respiratory disease index HRQoL instrument (CRD) found that prednisone use did not result in a significant (p = 0.14) overall health benefit (total score) when compared to placebo, although prednisone reduced the incidence of relapse and improved both lung function and dyspnea.

Physical activity

Three studies reported on physical activity related to the burden of COPD. A cross-sectional study using the Canadian national health survey data (1994–2007) found that approximately 68 % of obese and 60 % of non-obese COPD patients were inactive. Additionally, approximately 72 % of obese and 60 % of non-obese COPD patients reported activity restriction [23]. Furthermore, a cross-sectional study by Rocker [26] in patients with severe, stable COPD found that scores on the palliative performance scale from semi-structured interviews ranged from 50 to 70 % and that all patients had a score of 5 on the Medical Research Council dyspnea scale (i.e., they were too short of breath to leave their homes or were breathless when dressing or undressing). The significance of pain in COPD patients was reflected in pain-related interference in activities, which may partly account for the lower SF-36 physical component scores in HRQoL and the lower physical activity scores on the community health activities model program for seniors (CHAMPS) questionnaire [25].

Economic burden evidence

Overview

A total of 5 studies contained outcomes of interest and were included in this review. Of the 5 studies, 4 studies reported the patient level direct costs and 2 studies reported population level direct costs for COPD patients (Tables 5, 6).
Table 5

Summary of average annual patient level direct costs evidence (CAN$)

References (study period)

Categories

Patient group

Patient perspective inflated cost/patient

Societal perspective inflated cost/patient

Chapman et al. [1] (12 months)

All

All

$2444.17

$3910.39

Gender

Male

$1941.09

$2817.88

Female

$2926.30

$4956.03

Smoking status

Former smokers

$3348.67

$4702.55

Current smokers

$1357.06

$2958.41

Comorbidities

Yes

$2506.92

$4568.22

No

$2370.68

$3127.96

Education status

Less educated

$3043.48

$4540.89

More educated

$2142.85

$3638.46

Wouters et al. [37] (1 year)

All

All

$2378.59

$6693.37

Gender

Male

NR

$2741.62

Female

NR

$4254.24

Smoking status

Former smokers

NR

$4575.67

Current smokers

NR

$2877.75

Education status

Less educated

NR

$4418.73

Well educated

NR

$3539.53

Mittmann et al. [3] (52 weeks)

Moderate exacerbation

ITT population

$718.48

NR

Clinically evaluable population

$847.38

NR

Severe exacerbation

ITT population

10,712.14

NR

Clinically evaluable population

11,156.01

NR

Maleki-Yazdi et al. [59] (Oct 2009 and Jan 2010)

All

All

$4391.16

NR

Acute exacerbation

Clinically evaluable population

$3214.75

NR

ITT intention to treat, NR not reported

Table 6

Summary of average annual population level direct costs evidence (CAN$)

References (study period)

Population

Resource

Inflated 2012 CAN$

Dormuth et al. [60] (Jul 2007–Dec 2009)

Residents of British Columbia, 45+ years old

Medication (inhaled anticholinergic)

$26,298,835.28 (ministry paid: $13,276,279.45, out of pocket: $13,022,555.82)

Any hospital admission

$310,494,472.10

Emergency COPD admission

$59,456,281.50

Mittmann et al. [3] (52 weeks)

Mean age of 68.6 years

Moderate exacerbation

$182.7–$254.44 million

Severe exacerbation

$469.64–$642.26 million

Patient level direct costs

Overall, the average total cost per patient was reported from both a patient perspective and a society perspective (accounting for inflation) and ranged between CAN $2444.17–CAN $4391.16 (patient perspective) and CAN $3910.39–CAN $6693.37 (societal perspective) annually. The average cost per acute COPD exacerbation reported by Mittmann [3] and Maleki-Yazdi [59] ranged from $718–$11,156 and the cost was found to increase with the severity of the exacerbation. No studies were found to examine the relationship of cost to overall disease severity.

Two studies examined differences in costs based on patient characteristics. Chapman [1] and Wouters [37] both reported female COPD patients incurred more costs compared to male patients from both a patient and a societal perspective (additional $985/patient from a patient perspective, $1513–2138/patient from a societal perspective). In addition, these studies also found that former smokers incurred more costs than current smokers (additional $1992/patient from a patient perspective, $1698–$1744/patient from a societal perspective) and that COPD patients with less education incurred more costs than those who are more highly educated (additional $901/patient from a patient perspective, $879–902/patient from a societal perspective). Lastly, Chapman [1] reported that patients with comorbidities were more costly than those without comorbidities (additional $136/patient from a patient perspective, $1440/patient from a societal perspective).

Population level direct costs

Population level direct costs (in Canadian dollars) were examined in two studies (Table 6). Dormuth [60] found that residents of British Columbia who were dispensed an inhaled anti-cholinergic (IAC) medication (ipratropium or tiotropium) cost $26,298,835 annually over 2.5 years for IACs (Ministry of Health $13,276,279, out of pocket $13,022,556), $310,494,472 for any hospital admission and $59,456,281 for emergency COPD admissions over the 2.5 year period. The second study by Mittmann [3] estimated that moderate COPD exacerbations cost $182.70–$254.44 million annually while severe exacerbations cost $469.64–$642.26 million annually in Canada.

Discussion

COPD is one of the world’s most common health problems [2]. This review found evidence that the clinical, economic and humanistic burden of COPD is substantial in Canada. COPD patients were found to average 0–4 annual emergency department visits, 0.3–1.5 annual hospital visits, and 0.7–5 annual physician visits which are similar to the rates reported worldwide. Variance in these rates across studies may reflect population differences, methodological differences and/or treatment pattern differences between studies. In Canada, the health care services are provided by the private sectors but they are delivered through publicly funded health care systems. For instance, basic services such as physician care are provided by private doctors but the physician fees are paid for by the government. Hospital care is delivered by publicly funded hospitals which are mostly independent institutions incorporated under provincial Corporations Acts. The universal health care system, however, does not include coverage of prescription medication; drug benefit plans for eligible groups are available under provincial and territorial governments.

In terms of ED services, an international survey found that around the world, the percentage of COPD patients using ED services ranges from 1 % (China) to 25 % (Brazil) [61]. The relatively small number of ED visits found for Canadian COPD patients would suggest that the use of ED services for COPD patients may fall on the lower end worldwide. Hospitalization rates, hospital readmission rates, and the number of physician visits for Canadian COPD patients were found to be consistent with rates found in the US [6264]. Additionally, trends of increasing healthcare resource use as COPD worsens are consistent with worldwide data [61, 65].

Primary care has been reported to have the greatest proportion of worldwide burden in the treatment of COPD. Furthermore, increasing severity of COPD imposes a greater burden on the use of primary care resources [61]. Evidence was found that self-care management programs may help with reducing the number of ED visits, hospitalizations, and physician visits. Additionally, telephone support services were found to reduce the number of physician office visits. Integrated care programs, however, appear to reduce the mean number of hospitalizations but not ED visits.

COPD has a profound impact on patients’ quality of life [66]. Evidence found in this review, while not overwhelming, found that Canadians with COPD have a poorer quality of life. Worldwide data suggests that up to 45 % of COPD patients experience pain and that increases in pain are associated with disease progression [6772]. The significance of pain in COPD patients was reflected in greater pain-related interference on activities of daily living. In the Canadian Hidden Depths survey, COPD symptoms were found to have a significant effect on a range of daily activities (including climbing stairs, housework, getting dressed and sleeping) for a majority of respondents [73]. Clinicians face challenges in treating COPD related pain in that opioids, common pharmacotherapy, are not recommended for use in COPD patients, presumably due to their effects on the reduction of breathing rates which may further exacerbate COPD [4]. Additionally, this review found evidence that 60–72 % of COPD patients are inactive and/or have activity restrictions with obese patients having the highest percentages.

Obesity is one of the leading causes of overall morbidity and mortality [74, 75]. Thus it is not surprising that health consequences of obesity are seen in the COPD population and coupled with progressively worsening lung function. It is therefore important that more research is performed in order to better understand the impact of interventions on the quality of life and how to maximize patient functioning.

Data from this review found the average total cost per COPD patient ranged between CAN $2444 from a patient perspective to CAN $6693 from a societal perspective. Moreover, data suggests that the costs rise as the disease severity increases. The clinical burden review found evidence which indicates that healthcare resource utilization increases with exacerbation severity [3, 32], increasing age [46, 76], and comorbid cardiovascular disease [53]. Thus, clinicians should focus on ensuring proper diagnosis, optimizing appropriate care, and the importance of personalized medicine.

This review, like all reviews, is limited by publication bias with respect to the articles that are available. In addition, the articles in this review were a priori limited to the English language and restricted to those published since 2000 to examine the most recent data as the practice of medicine and related burden may change over time. Spatial restrictions were also applied, limiting studies to Canadian populations. However, in spite of these limitations, this review was systematic in nature and therefore by reviewing all available and relevant data, it provides a better and comprehensive understanding of the literature with respect to clinical, humanistic and economic burden of COPD in the Canadian population.

Conclusions

COPD is currently the fourth leading cause of death among Canadians. This review found that COPD causes a profound impact on healthcare resources and produces a significant clinical, humanistic and economic burden in Canada. This review found evidence that self-care management programs, telephone support services, and integrated care programs may help limit the overall burden to Canadian patients and society.

Abbreviations

AECOPD: 

acute exacerbation of chronic obstructive pulmonary disease

BMI: 

body mass index

BPI: 

Brief Pain Inventory Scale

CHAMPS: 

community health activities model program for seniors

COPD: 

chronic obstructive pulmonary disease

CRD: 

chronic respiratory disease

CRQ: 

Chronic Respiratory Questionnaire

CV: 

cardiovascular

ED: 

emergency department

GOLD: 

global initiative for chronic obstructive lung disease

HRQoL: 

health-related quality of life

IAC: 

inhaled anti-cholinergic

NICE: 

National Institute for Health and Care Excellence

PRISMA: 

preferred reporting items for systematic reviews and meta-analyses

PY: 

patient years

RCT: 

Randomized Controlled Trial

SF-36: 

short form 36

SGRQ: 

St George’s Respiratory Disease Questionnaire

SIP: 

sickness impact profile

STROBE: 

strengthening the reporting of observational studies in epidemiology

Declarations

Authors’ contributions

All authors contributed to the design and protocol of the study. TD, AI, SZ conceived, funded and participated in the design and coordination of the literature review. MB and VZ coordinated and conducted the literature review, analyzed the results and drafted the manuscript. All authors reviewed the results of the analysis and contributed to the development. All authors read and approved the final manuscript.

Acknowledgements

Funding for this study was provided by GlaxoSmithKline Inc. Canada. All listed authors meet the criteria for authorship set forth by the International Committee for Medical Journal Editors. The authors wish to acknowledge Emma Goodall for her critical review of the final manuscript.

Compliance with ethical guidelines

Competing interests TD, AI, and SZ are employees of GlaxoSmithKline Inc. Canada. ASI is also an assistant professor (part-time) in the Department of Clinical Epidemiology and Biostatistics at McMaster University, Hamilton, Ontario, Canada. VZ and MB are former employees of Optum.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
GlaxoSmithKline
(2)
GlaxoSmithKline
(3)
Clinical Epidemiology and Biostatistics, McMaster University
(4)
Optum

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